Monitoring Fetal Growth

MONI TORI NG
FETAL
GROWTH
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Sel f - I nst r uct i on
Manual
2011
1
5
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2
Fesci na RH
De Muci o B
Mar t nez G
Al emn A
Sosa C
Mai nero L
Rubi no M
Sci ent i f i c Publ i cat i on CLAP/WR 1586.02
2nd edi t i on
Lat i n Ameri can Cent er for Peri nat ol ogy
Women & Repr oduct i ve Heal t h - CLAP/WR
Monitoring
Fetal
Growth
Self-Instruction
Manual
2
nd
edition
Fescina RH
De Mucio B
Martnez G
Alemn A
Sosa C
Mainero L
Rubino M
Latin American Center for Perinatology
Women and Reproductive Health CLAP/WR
Familiy and Community Health
Pan American Health Organization / World Health Organization
www.clap.ops-oms.org
http://new.paho.org/Clap
Scientifc Publication CLAP/WR 1586.02 Montevideo - Uruguay - 2011
Cataloging in Publication:
Fescina RH, De Mucio B, Martnez G, Alemn A, Sosa C, Mainero L, Rubino M. Monitoring fetal
growth. 2nd ed. Montevideo: CLAP/WR; 2011. (CLAP/WR. Scientifc Publication; 1586)
SBN: 978-92-7513228-9
1. Fetal development
2. Gestational age
3. Medical Records
4. Data Systems
5. Training Material
I. CLAP/WR
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Latin American Center for Perinatology/ Women and Reproductive Health - CLAP/WR Pan
American Health Organization / World Health Organization - PAHO/WHO
P.O. Box 627, 11000 Montevideo, Uruguay
Telephone: +598 2 487 2929, Fax: +598 2 487 2593
http://new.paho.org/clap
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MONTORNG FETAL GROWTH: Self-nstruction Manual
2nd edition
Scientifc Publication CLAP/WR 1586.02
Roberto Porro, art design
2 Monitoring Fetal Growth
Latin American Center for Perinatology - Women and Reproductive Health CLAP/WR
TABLE OF CONTENTS
Pag
INTRODUCTION 4
FACTORS AFFECTING INTRAUTERINE GROWTH 9
PHYSIOPATHOGENESIS OF INTRAUTERINE GROWTH RESTRICTION 11
DIAGNOSIS 13
- Calculatlon of gestatlonal age 14
DIAGNOSIS OF IUGR WITH KNOWN OR ESTIMATED GESTATIONAL AGE 16
DIAGNOSIS OF IUGR WHEN THE GESTATIONAL AGE IS EITHER
UNRELIABLE OR UNKNOWN IN PREGNANT WOMEN CAPTURED LATE
FOR CONTROL
30
- Growth rate patterns based on the earller value 30
- The fetal abdomlnal clrcunference/femur length ratlo 32
DIFFERENTIAL DIAGNOSIS BETWEEN A FETUS WITH APPROPRIATE
GROWTH AND IUGR WITH UNCERTAIN LMP AND LATE CAPTURE 33
DIFFERENTIAL DIAGNOSIS BETWEEN SYMMETRIC IUGR AND ERROR IN
THE ESTIMATION OF GESTATIONAL AGE BY LMP
37
PROPOSALS FOR THE SOUND USE OF THE FETAL GROWTH
SURVEILLANCE METHODS
39
OBSTETRIC MANAGEMENT OF INTRAUTERINE GROWTH
RESTRICTION
41
A) Antenatal management 41
8) Chlldblrth 42
C) Durlng labor 46
EXERCISES USING THE PERINATAL COMPUTING SYSTEM FOR THE
ASSESSMENT AND MONITORING OF FETAL GROWTH
49
- welght by gestatlonal age 49
- Llstlng of medlcal records 56
- Plsk estlmatlons 58
- Hlstory of L8w 59
- Smoklng hablt 59
- Preclampsla 60
- Multlple pregnancy 60
- 8aslc statlstlcs 62
- Plrst trlmester 63
- Second trlmester 64
- Thlrd trlmester 65
- Pourth trlmester 66
- Answers to the exerclses uslngers to the exerclses uslng the perlnatal lnformatlon
system for the assessment and monltorlng of fetal growth 68

3
Monitoring Fetal Growth
Tables
Table |- Plsk factors ln a Latln Amerlcan populatlon (8razll, Argentlna and Uruguay) 14
Table ||- Maternal welght by helght by gestatlonal age (pl0-p90). (22) 19
Table |||- Lnectlveness of fundal helght, maternal welght galn, fetal abdomlnal
clrcumference, fetal head clrcumference, 8PD and ollgoamnlos measured
by ultrasonography to predlct SGA (24) 24
Table |v- 8ehavlor of fetal growth when there ls an error ln the estlmatlon of
gestatlonal age by LMP and asymmetrlc and symmetrlc growth restrlctlon 38
Table v - Dlagnosls of |UGP uslng rlsk factors, fundal helght and maternal welght galn
as a screenlng procedure, and ultrasound as a conrmatlon procedure ln a
populatlon wlth a l4% prevalence of |UGP 40
Table v|- Preventlon of the blrth of small for gestatlonal age lnfants wlth low-dose
asplrln. The common odds ratlo (summary measurement of the results of
the 7 studles) shows the slgnlcant protectlve enect of lts admlnlstratlon.
Thls protectlve enect of asplrln would reduce the SGA llkellhood by 20%
(between l0% and 30%) 42
BIBLIOGRAPHY 73
MONITORING FETAL GROWTH
SELF-INSTRUCTION MANUAL
INTRODUCTION
Normal embryo-fetal growth can be defned as the growth that results from
uneventful cell division and growth, yielding a full-term term infant with full
expression of its genetic potential as its end product. This is very diffcult
to determine in clinical practice, because it is impossible to measure the
fetus's intrinsic growth potential. Hence, the diagnosis of normal fetal
growth is based on the comparison of the anthropometric measurements
of the suspected abnormal newborn against standards obtained from
neonates considered healthy on the grounds that they are the product of
pregnancies with no known abnormalities.
For practical clinical purposes, a fetus is considered to have an intrauterine
growth restriction (UGR) when its weight is estimated to be lower than the
weight appropriate for its gestational age. f the child is born at the time of
diagnosis, its weight would be below the lower limit of the standard birth
weight for that specifc gestational age. Most authors agree that this lower
limit (SGA) corresponds to percentile 10 of the gestational age curve.
However, it is important to highlight that this defnition of growth restriction
includes as abnormal 10% of the population of normal newborns. There is
evidence that the occurrence of adverse perinatal outcomes is more likely
in those infants that deviate more from the 10th percentile, as those that
are below percentile 3. (1-3).
In a strict sense, it is important to consider that:
a) not all children with a birth weight less than the 10th
percentile values have an UGR; this could be the case of
a normal child with a low growth potential.
b) A birth weight above the 10th percentile does not
necessarily rule out the diagnosis of UGR, since it may
have been a fetus that had grown well up to a certain
point during pregnancy, but then it begins to fall behind,
so even when the fnal weight is over P10, there was
indeed a growth restriction that led it to go, for instance,
from percentile 90 to percentile 15).
5
Exercise 1
You may remember that although for practical purposes the concept of SGA is
almost the same as UGR, not all SGAs are necessarily UGRs, and conversely,
not all UGRs are necessarily SGAs. Below are two examples that illustrate this.
Assuming that the intrauterine weight of two cases (A and B) was estimated at
different gestational ages, and that the following values were obtained:
Case A Case B
30 weeks
35 weeks
40 weeks
1800 g.
2300 g.
3000 g.
900 g.
1900 g.
2800 g.
5000
4000
3000
2000
1000
G
r
a
m
s
P
90
P
10
Amenorrhea, in weeks
25 27 29 31 33 35 37 39 41
Figure 1 Weight by GA curve, showing P10 and P90
f the values are plotted in Figure 1, you will see that case A always falls between
P10 and P90, while case B is always below P10.
However, the course evidenced by the curves indicates weight deterioration
in case A (percentile drop), while case B remains always within the same
percentile. Therefore, strictly speaking, case A is an UCR without being a SGA,
while case B is a SGA, but not a restriction.
n an attempt to partially avoid these problems, other authors proposed using
the concept of normal growth at birth based on certain weight limits, for example
2500 grams (the term low birth weight (LBW) is applied to all newborns weighing
less than 2500 grams at birth, regardless of gestational age).
Considering just the birth weight also poses a serious problem, because it does
not provide an accurate estimation of the proportion of small for gestational age
(SGA) infants (4). At the end of gestation, the 10th percentile reaches 2,900
- 3.000g (depending on the standard used). Therefore, all infants weighing
between 2,500 and 2900-3000 g that are really small for gestational age, would
not be classifed as such if one applies the defnition that considers a 2,500 g
limit. This weight range (from 2,500 to 2,900-3,000g) accounts for most children
born small for gestational age.
Exercise 2
Let us review the concepts of SGA and LBW. Try to locate the 4
values listed below in Figure 1.
You will notice that the values C and F fall between percentiles 10 and 90. D and
E are located below P10. This means that the latter are actually SGA. Of the two
SGAs in our chart, only D has a LBW. f you ranked case C as an appropriate
weight preterm, cases D and E as SGA full-terms and case F as a full-term
infant with an appropriate weight, your answer was correct; otherwise, re-read
the above paragraphs.
Therefore, the assumption that all newborns weighing less than 2,500 grams with
a gestational age greater than 37 weeks had an intrauterine growth restriction is
incorrect; it is also wrong to consider that all children weighing more than 2,500
g. had an adequate growth.
Despite the above issues, which should be taken into account and are under
investigation, the weight-by-gestational-age standards are still helpful to classify
infants.
t is frequent to see inadequate curves with methodological problems, or local or
foreign standards developed ignoring certain factors that alter fetal growth and
G. A. Weight
Rank the
case
Case C
Case D
Case E
Case F
35
37
39
39
2600 grs.
2300 grs.
2800 grs.
3350 grs.
7
act as confounding variables that need to be controlled. These factors include
(among others), the mother's weight gain, smoking habits and socioeconomic
level. For example, the birth weight observed in Aberdeen, Scotland had changed
15 years after the frst description of the standards in 1968 (1). Growth standards
should be revised every 10 years, to see if they have changed so substantially in
the population, as to warrant changing the reference standards.
Figure 2 shows the curve obtained at the Latin American Center for Perinatology.
The sample included 14,814 newborns (NB) from public hospitals in Montevideo
- Uruguay, Sao Paulo - Brazil and Buenos Aires and Neuqun - Argentina.
5000
4000
3000
2000
1000
G
r
a
m
o
s
P
90
P
10
Amenorrhea in weeks
25 27 29 31 33 35 37 39 41
Figure 2 Standards developed by CLAP/WR for neonatal weight by
gestational age
All infants met the following requirements: a) singleton pregnancies without any
known morbidity, b) non-smoking mothers with known and undoubted date of
last menstruation, c) antenatal care started before 22 weeks, d) mothers with
adequate weight gain, c) lower-middle socioeconomic class, and f) living at an
altitude not greater than 500 meters above sea level. (5)
SGAs exhibit a perinatal mortality rate 8 times higher than infants born with
appropriate weight for gestational age; the risk of asphyxia at childbirth is 7 fold.
Neonates often present with hypoglycemia, hypocalcemia and polycythemia. f
the UGR occurs in a preterm pregnancy, the child's perinatal risk is higher, due
to the association of two conditions (2, 6, 7).

9
FACTORS AFFECTING INTRAUTERINE GROWTH
Growth implies a process of synthesis, ranging from simple molecules
to complex biomolecules; this process occurs simultaneously with cell
differentiation, and it leads to the development of organs and tissues in
charge of complex and interrelated functions.
Although the intimate processes remain unknown, it is a known fact that
growth can be altered by several factors. Current knowledge shows that
about 60% of the cases of UGR are associated with certain specifc risk
factors (3, 8). These factors can be broken down depending on the time
at which they are detected:

a) Preconception risk factors,
b) Risks identifed during pregnancy
c) Environmental and behavioral risks
a) Preconception risk factors
1. Woman's low education and low socioeconomic status.
2. Extreme ages (<16 or> 40 years)
3. Short height <150 cm
4. Severe malnutrition
5. Chronic diseases (hypertension, kidney disease, diabetes with
vascular disease, chronic lung disease, mesenchymal diseases
with vascular changes, hemoglobinopathies)
6. History of SGA
b) Risk factors detected during pregnancy
1. Multiple pregnancy
2. Weight gain of less than 8 kg at term
3. Birth interval of less than 12 months
4. Pregnancy-induced hypertension / preeclampsia-eclampsia
5. Antiphospholipid syndrome
6. Anemia
7. nfections: viral (rubella, cytomegalovirus, varicella, herpes
zoster) Parasitic (toxoplasmosis, malaria)
8. Congenital malformations
9. Genetic disorders
10. Exposure to teratogens
c) Environmental and behavioral risk factors
1. Smoking during pregnancy
2. Heavy alcohol consumption
3. Excessive consumption of caffeine
4. Drug Addiction
5. High altitude above sea level
6. Stress
7. Lack of or inadequate antenatal care. Excessive physical work
11
PHYSIOPATHOGENESIS OF INTRAUTERINE GROWTH
RESTRICTION
SGAs are classically divided into two types; in the case of symmetric SGAs, all
measures (head circumference, length, weight) are reduced, and asymmetric
SGAs only have a weight reduction, with normal-sized head circumference
and body length (9, 10). The former are usually due to causes that occur
at early stages of pregnancy (e.g., chromosomal abnormalities, rubella, etc.).
In the latter, the asymmetric growth is due to insults that appear in the third
trimester (e.g, pregnancy-induced hypertension).
These different growth disorders are due to the asynchronous growth rates of
the various tissues, i.e., tissues present their hyperplasia at different times of
gestation. Tissues are more sensitive to damage at their peak growth rate. The
so-called critical period.
Figure 3 shows that the growth peak of the neural tissue is around 22 weeks
gestation, while the adipose tissue changes grows more at 34-35 weeks
gestation (11).
Adiposytes Neurons
Long
bones
Early and
prolonged
harm
Late
onset
harm
Acts at the
critical period
15 20 25 30 35 40
Weeks of gestation
G
r
o
w
t
h

r
a
t
e
Results
Reduced head cir.
Length
Weight
Symmetric
SGA
Normal head circ.
Normal length
Reduced weight
Asymmetric
SGA
Neurons
Long bones
Adipositosis
Yes
Yes
Yes
Neurons
Long bones
Adipositosis
No
No
Yes
Figure 3 Critical periods of the different tissues and perinatal outcomes
depending on the time of occurrence and the duration of the
noxa
A noxa that acts early and is maintained throughout pregnancy (e.g. rubella)
will impair growth overall (length, weight, head circumference) and it will result
in a harmonic and symmetric growth restriction, known as Winick's type
1 GR, or Campbell's low profle (12; 13). n contrast, when the noxa acts
later (e.g., preeclampsia) its worst impact is on weight, while height and head
circumference tend to remain within normal ranges. This growth restriction
is disharmonious and asymmetric, and it is known as Winick's type or
Campbell's late fattening (12; 13).
The above is what usually happens, but it is noteworthy that if an offending
agent acts later and it is severe enough, it may impact on the size of the skull,
but to a lesser extent than on weight; the best indicator of the latter parameter
is the fetal abdominal circumference (FAC).
13
DIAGNOSIS
Antenatal surveillance of fetal growth should include a) diagnostic
screening methods to be used routinely in antenatal care, at all the levels
of care and b) methods to confrm the diagnosis that require a certain level
of technological complexity, and that are generally found in specialized
facilities.
Standards of care should propose prevention strategies that enable the
monitoring of fetal growth for the entire population of pregnant women,
using a tiered decision-making system that facilitates a rational distribution
of resources.
n general, the frst contact between the woman and the health team
occurs when the woman is already pregnant, so the identifcation of risk
factors and subsequent interventions has to be done during antenatal
care, which should start early, be regular, continuous and universal
(100% coverage).
An early capture allows the team to detect risk factors, enabling them
to correct those that are modifable; in addition, in subsequent controls
the pregnant woman should be assessed to ratify or rectify the primary
diagnosis, and thus decide what level of complexity is appropriate for
that delivery.
Many scoring systems have been proposed to identify pregnancies at
increased risk of producing small-for-gestational-age infants, but they all
failed to meet the expectations following the original publication.
For this reason, instead of a scoring system, we recommend using a list
of factors associated with UGR, and whose presence in the pregnant
woman may enable the health care providers to identify the case at a
high risk of UGR. The selection of the factors must be made taking
into account, among other criteria, their frequency in the population,
the degree of association with damage and their statistical signifcance.
For example, Table 1 provides a list of factors developed by CLAP with
their corresponding frequency in the population, relative risk (RR) and
confdence interval. The population included 31,588 pregnant women
from public hospitals in Montevideo Uruguay, Sao Paulo - Brazil and
Buenos Aires and Neuqun - Argentina.
The odds of diagnosing UGR and the methods that can be used depend
primarily on the precise knowledge of the last menstrual period and the
time the pregnant woman is captured for antenatal care.
Table 1- Risk factors in a Latin American population (Brazil,
Argentina and Uruguay)
Risk Factor Frequency in
population %
Relative
Risk
95% Confidence
interval
History of SGA
Smoking habit (10 o +)
Multiple pregnancy
Pregnancy-induced hypertension
Preeclampsia
Hemorrhage 2nd trimester
Weight gain < 8 kg.
Oligoamnios
14
26
1
7
4
0.5
16
0.5
1.5
1.6
3
1.4
2.1
1.6
2.1
2.9
1.1 - 2.7
1.1 - 2.2
2.0 - 3.4
1.2 - 1.7
1.9 - 3.2
1.2 - 2.7
1.3 - 3.5
1.7 - 5.0
Another research study in the population of Pelotas, Brazil in 1996 (14) studied
other factors such as maternal age under 20 years (OR 2.4, 1.2 - 5), low income
(OR 14.3; 1.9 - 105), maternal height <150 cm (OR 2.9, 1.4 - 6.2) and inadequate
antenatal control (OR 2.2, 1.2 - 4.2).
Calculation of gestational age
Given the signifcance of knowing the precise gestational age to determine
the duration of pregnancy and properly evaluate fetal growth, we will
briefy review the clinical and laboratory methods used to determine it.
The clinical method most commonly used consists of asking for the date
of the last menstrual period and the regularity of the woman's menses.
This clinical data is based on a marker remembered by the woman
as an approximation to the time of ovulation and therefore, the time
of conception. The anamnesis should be taken in a quiet,and private
place, and it is the more reliable the earlier the data are collected. f,
in addition, this date also coincides with the clinical examination of the
fundal height as defned in the frst 12 weeks of pregnancy, gestational
age is confrmed. While this method is more suitable for patients who are
seeking pregnancy, it is estimated that in over 30% of the population it is
not the most appropriate technology to assess gestational age (16).
An alternative method used is the clinical estimation of gestational age
by the physical examination of the fundal height. However, there is also
evidence that this technology has little value (17;18). Used in isolation,
this method has a variability of 3 weeks, except for measurements
15
between 8 and 9.9 cm. or 10 and 12 cm. for weeks 13 and 14 weeks
respectively, whose spread is 2.5 weeks. Finally, fetal movements
perceived by the mother and frst auscultation of fetal heart beats with
Pinard's or De Lee'd stethoscope or Lee should be avoided because
their spread is 5 weeks.
When in doubt about gestational age, the ultrasound is the only method
that can diagnose it accurately - accuracy being greater the earlier it is
performed (Fig. 4). (11)
Some authors (16; 19; 20) believe that a reliable last menstrual period is
less precise than the gestational age estimated by an early ultrasound. n
the frst trimester of pregnancy and after the 8th week, when the embryo
becomes visible, the parameter used to estimate gestational age is the
crown-to-rump length, which has a linear relationship with gestational
age. n the second and third trimester, the parameter used is the BiParietal
Diameter (BPD), in isolation or combined with other parameters, such as
the Femur Length (FL).
10
5
9
13
17
21
25
29
33
37
41
16 22 28 34 40 46 52 58 6470 76 82 88 94 100 mm
Weeks
F
e
m
u
r
D
.

B
P
.
L.C
N P
95
P
50
P
5
P
95
P
50
P
5
P
95
P
50
P
5
Central value and
confidence limits
for estimating
gestational age
based on the
ultrasound
measurements of:
Femur length
Biparietal D.
Ceph.-Buttocks length
Figure 4. Estimation of gestational age based on the fetal anthropometric
measurements using two-dimensional ultrasound. (21)
DIAGNOSIS OF IUGR WITH KNOWN OR ESTIMATED
GESTATIONAL AGE
UGR can be suspected in pregnant women presenting with a known
gestational age, or in women in which no clinical or laboratory features
permit to estimate the gestational age with an acceptable error. Below is
the setting where the gestational age is known.
As a general concept, we must consider that UGR is rarely detected
clinically before 30-32 weeks. This clinical picture can be associated
with decreased fetal movements, oligohydramnios, low maternal weight
gain (Fig. 5), and slower growth or arrested enlargement of the uterus in
relation to the duration of pregnancy.
This latter clinical sign is important for the diagnosis, while the serial
measurement of the fundal height with a fexible and inextensible
measuring tape performed at each antenatal visit, allows us to observe
the growth of the uterus and to compare it with the normal patterns (Fig.
6).
Although there is no compelling evidence regarding the use of fundal
height measurement s(18) and the detection of UGR, its serial use and
in conjunction with other clinical features, helps control the normal course
of fetal growth (1). t has been reported that abdominal palpation detects
only 30% of the SGAs, so, if this diagnosis is suspected, as is the case
with the measurement of the fundal height, the diagnosis should always
be complemented with laboratory testing (1).
UGR should be suspected when the values of maternal weight gain
are lower than those corresponding to the 25th percentile of the normal
standard curve, or lower than the fundal height corresponding to the 10th
percentile of its appropriate normal standard curve. As shown in Table
ll, if both methods (the abnormal values of maternal weight gain and
fundal height) are used in combination to defne the suspicion of UGR,
sensitivity (the ability to diagnose the true UGR) reaches 75%.
17
M
a
t
e
r
n
a
l

w
e
i
g
h
t

g
a
i
n
Kg.
15
13
16 20 24 28 32 36 40
11
9
7
5
3
1
0
Weeks of amenorrhea
P
90
P
75
P
50
P
25
P
10
Figure 5. Maternal weight gain in Kg by gestational age. Longitudinal
prospective study N = 1023 weight measurements. (22)
P
90
P
50
P
10
35
33
31
29
27
25
23
21
19
17
15
13
11
9
7
13 15 17 19 21 23 25 27 29 31 33 35 37 39 sem.
cm
F
u
n
d
a
l

h
e
i
g
h
t
Figure 6. Fundal height in cm by gestational age. Longitudinal prospective
study. N = 1074 measurements. (23)
Exercise 3
Locate the weight gain values for gestational age on fgure 5, by subtracting
the usual weight from the weight value obtained for each week, using the
data listed below. Maternal usual weight: 56 Kg.
Week Weight gain
Maternal
weight (kg.)
16
24
27
32
34
58.7
61.5
62.5
63.0
63.5
19
Table II - Maternal weight by height by gestational age (p10-p90). (22)
Join the 5 points that you have found in fgure 5 and obtain the maternal weight
gain curve for that case.
You will see that the curve of the case studied crosses it and falls under percentile
25, which suggests that we are facing an UGR.
Exercise 4
Locate in fgure 6 the fundal height values for each of the gestational ages below
Week Fundal height (cm)
16
24
27
32
34
14
21
23
24
25
Join the 5 points that you have found in fgure 6 and you will obtain the course
of the fundal height of this case.
You will see that the curve that corresponds to the case falls below percentile
10, suggesting this is a case of UGR.
The mother's pre pregnancy weight is often not available, making it impossible
to calculate her weight gain, as shown above. n this case, one can use the
table that plots the maternal weight for height by gestational age (Table ).
The table shows the weights corresponding to percentiles 10 and 90 for each
gestational age and maternal height.
Pregnant women with weight-for-height values lower than percentile 10 indicate
a poor weight. The cases the exceed percentile 90 are considered excessive.
For example, a pregnant woman that is 159 cm tall at a gestational age of 20
weeks and weighs 58 kg is within the normal values for weight and height, since
this value is within 54.4 kg (P10) and 66.6 KG (P90).
21
Exercise 5
State whether the maternal weight for height of the 5 pregnant
women reached at the gestational ages listed below is appropriate.
Maternal
height
(cm.)
Maternal
Weight
(kg.)
Is maternal weight for
height by gestational
age appropriate?
Gest.
age
(wk.)
A
B
C
D
E
Yes No
53
58
46
55
67
154
160
150
156
162
27
20
18
31
36
If you answered that ladies A, C, and D do not have an appropriate weight
for their gestational age and height, (contrary to ladies B and E), you have
understood the use of the chart correctly. f not, read from page 16 onward.
KNOWN AND RELIABLE GESTATIONAL AGE
Serial measurements
Confirmation ultrasound
using GA-dependent
growth indicators
Appropriate fetal growth- low
risk antenatal control
D i a g n o s i s o f I U G R
Ruled out
See algorithm for the differential diagnosis between
symmetric and asymmetric IUGR and management
Confirmed
Estimation of
Gestational age by
ultrasound
Ultrasound after the
3rd trimester using
GA independent
growth factors
Fundal height
Mothers weight
Estimation of volume amniotic fluid
Investigate risk factors
Values < lower limit
Oligohydramnios
Presence of risk factors
Distance curve of fetal
abdominal circumference and
head circumference by
gestational age
By Crown-to-rump length
8-13 weeks
By BPD after 12 weeks
By Femur length after
13 weeks
Early capture
Before 20 weeks
.
Abd. Circ
Femur length
Growth rate based on previous
value of fetal abdominal
circumference
Ratio =
C
l
i
n
i
c
a
l
t
e
s
t
i
n
g
C
o
m
p
l
e
m
e
n
t
a
r
y
m
e
t
h
o
d
s
Yes
Yes
No
Yes
No
No
Figure 7. Algorithm for the diagnosis of IUGR
There is no doubt that ultrasound is the most precise test available to confrm
the diagnosis (24) (Table ). Added to this advantage, through a number of
fetal anthropometric measurements it permits to establish the type of restriction.
The variables most commonly used to determine fetal growth and type of
restriction are the fetal head and abdominal circumferences (Figures 8 and 9).
The measures thus obtained are compared with the normal patterns, in this
case using the growth curves according to gestational age (distance curve).
Obstetric ultrasound also provides information regarding the amount of amniotic
fuid and the maturity of the placenta, which are parameters used in the clinical
management of intrauterine growth restriction. The serial measurements
of abdominal circumference and fetal weight estimation are better than the
isolated estimates of fetal weight for the diagnosis of UGR. However, the
interval between ultrasound scans should be greater than two weeks to prevent
a greater proportion of incorrect diagnoses (false positives) (1).
370
350
330
310
290
270
250
230
210
190
170
150
130
110
90
70
14 16 18 20 22 24 26 28 30 32 34 36 38 40
Head
circumference
mm
P
95
P
50
P
5
Weeks of amenorrhea
Figure 8 - The fetal head circumference measurements in the
symmetric growth restriction (- - - ) fall early (24 weeks) below
normal limits (percentile 5), while in the asymmetric restriction
(.....) measurements usually remain within normal limits. (15)
23
mm.
390
370
350
330
310
290
270
250
230
210
190
170
150
130
110
90
70
15 17 19 21 23 25 27 29 31 33 35 37 39
Weeks of amenorrhea
A
b
d
o
m
i
n
a
l

c
i
r
c
u
m
f
e
r
e
n
c
e
P
50
P
5
Figure 9 - The fetal abdominal circumference falls below the normal
range (percentile 5) around 32 weeks in the types of restrictions, so
this measure is the most sensitive indicator. In the case of symmetric
restrictions (- - - ), its fall occurs later than the asymmetric restrictions
of the head circumference (24 weeks) (.....). (15)
Table III-Effectiveness of fundal height, maternal weight
gain, fetal abdominal circumference, fetal head
circumference, BPD and oligoamnios measured by
ultrasonography to predict SGA (24)
Measured Variable <
P10
Sens.
%
Sp.
%
PPV
%
NPP
%
PLR NLR AGA
Maternal weight gain (GP)
FH or GP
Biparietal diameter
Oligoamnios
Head circumference
Fetal abdominal circumference
Fundal height (AU)
50 %
75 %
67 %
28 %
42 %
94 %
56 %
79 %
72 %
93 %
98 %
100 %
100 %
91 %
60 %
63 %
67 %
28 %
42 %
94 %
80 %
72 %
82 %
67 %
28 %
42 %
94 %
77 %
2.38
2.68
9.57
14.0
100
100
6.22
0.63
0.35
0.35
0.73
0.58
0.06
0.48
< P10
2 P10
< P25
2 P25
< P25
2 P25
< P10
2 P10
< P5
2 P5
< P5
2 P5
< P5
2 P5
Si
No
20
16
18
18
27
9
34
2
24
12
15
21
10
26
5
53
12
46
16
42
0
58
4
54
0
58
1
57
Prevalence of UGR in the population under study (high risk) 38%.
AGA: Appropriate for gestational age
Sens: Sensitivity
Sp: Specifcity
PPV: Positive Predictive Value
NPV: Negative Predictive Value
PLR: Positive Likelihood Ratio
NLR: Negative Likelihood Ratio
25
Known gestational age with no doubts
Distance curve of the fetal
abdominal circumference
Between P5 and P95
Between P5 and P95 Lower than P5
Lower than percentile 5
Distance curve of the fetal head
circumference or femur length
Normal
fetal growth
Normal
fetal growth
Asymmetric IUGR Symmetric IUGR
Increase
lower tan
expected
Increase
as
expected
Fetal abdominal circumference
growth rate curve based
on previous value
Normal growth
or symmetric IUGR
Fetal Abdominal
Circumference/
Femur Length ratio
P10 < 4.25 P10 2 4.25
No Yes
Figure 10. Algorithm for the differential diagnosis between normal fetal
growth and symmetric and asymmetric IUGR.
Exercise 6
Differential diagnosis between appropriate fetal growth and UGR with known
and reliable fetal gestational age.
To do this exercise, you will be using fundal height charts (page 17), maternal
weight gain charts (page 17), fetal abdominal circumference (page 23), fetal
head circumference (page 22), and algorithms for the diagnosis of UGR
(page 21) and for the differential diagnosis between fetuses with appropriate
growth and fetuses with symmetric and asymmetric UGR (page 25).
The exercises have a sequence such that the questions should be answered as
they are formulated. Do not go any further with your reading without complying
with this requirement.
Mrs. ZZ is on her 34th week of pregnancy; the date of her LMP is certain,
and in accordance with an early ultrasound; furthermore, she has attended
3 previous antenatal visits. n this, her fourth visit to the Health Center, her
obstetric examination fndings include:
Mrs. ZZ
Gestational age
Current weight
Usual weight
Blood pressure
Fundal height
34 weeks
62 kg.
53 kg.
120/70 mmHg.
25 cm.
Which would be your presumptive
diagnosis?
Fetus with a normal growth
Fetus with a growth restriction
Macrosomic fetus (large)
None of the above
Assuming you can order tests to confirm
the diagnosis, which would you ask?
Fetal abdominal circumference (ultrasound)
Maternal abdominal circumference
Biparietal diameter (ultrasound)
None of the above
f you chose the fetal abdominal circumference measured by ultrasound, you
are on the right track; you may go on.
f you chose any other alternative, re-read pages 16 to 25 and see the algorithm
for the diagnosis of UGR on page 21 before you go on.
What diagnosis would you suggest and what would you do if the measurement
of the fetal abdominal circumference was:
27
Fetal diagnosis
Normal fetal growth
IUGR
Macrosomic
None of the above
Fetal abdominal
circumference
300 mm 266 mm
Recommended Management
Proceed with antenatal control for low-risk pregnancy
Refer to high risk
Special tests to determine IUGR type
Oral Glucose Tolerance Test
Fetal abdominal
circumference
300 mm 266 mm
f the measurement of the fetal abdominal circumference was 300 mm,
the diagnosis is that of normal fetal growth, since the value is between
5 and 95 percentile of the normal pattern and there was probably an
error in the measurement of fundal height. The action recommended is to
continue with low-risk antenatal care.
f the measurement of fetal abdominal circumference was 266 mm, the
diagnosis is UGR, since the value is below the 5 percentile of the normal
pattern. If you decided to continue with special tests to determine the
type of UGR, you are going the right way and you may continue. f your
answers do not match the statements above, review the algorithms on
pages 21 and 25.
What other assessment would you order?
or Femur length
Measurement of fetal head circumference
Growth rate curves according to
previous value
Measurement of mothers height
Measurement of estriol levels
If you chose the fetal head circumference and femur length, the decision was
correct. Otherwise, you should read the diagnostic algorithm to differentiate
between normal fetal growth and symmetric and asymmetric UGR (page 25)
before you go any further.
Based on the results of the fetal head circumference obtained, tick the diagnosis
that you consider correct.
Head circumference
320 mm.
290 mm.
IUGR
Symmetric Asymmetric
f you concluded that a 320 mm fetal head circumference indicates an asymmetric
UGR and the 290 mm HC was a symmetric UGR, you are right. Otherwise,
re-read pages 16 to 25.
Exercise 7.
Differential diagnosis between fetus with an appropriate growth and UGR with
unreliable date of LMP and early capture.
Do this exercise using the diagnostic algorithms for UGR on pages 21 and 25.
Mrs. YY has been pregnant for a short time; the uterus has not reached the
navel and she cannot remember the date of her last menstruation.
What would you do in this case?
Check the right answer
You would hurry to ask for a test
to estimate gestational age
You would not worry until the last trimester
because it is then that it is important to know it
If you answered that you would wait until the last trimester, see the diagnostic
algorithm for UGR on page 21 and read pages 14 to 16 again.
29
Choose the parameter you consider most important for the cases in which you
need to estimate gestational age:
Choose the parameter you consider most
important when you need to estimate gestational age
Crown-Rump Length (CRL) or biparietal diameter (BPD)
or femur length according to the size of the fetus
Amniotic fluid test
Measurement of the fetal abdominal fluid
Measurement of fundal height
f you answered Crown-Rump Length (CRL) or biparietal diameter or femur
length, you can continue.
f you answered another choice, go back to the diagnostic algorithm on UGR
and read page 21 and pages 14 to 16 again.
Let us assume that the gestational age was properly estimated, that pregnancy
carried on, and that at 32 weeks you suspect an UGR because the fundal
height and the mother's weight gain are below normal values (P10 and P25
respectively).

What tests would you order?
Calculation of the FAC/Femur Length ratio
Measurement of the biparietal diameter
None of the above
f you answered fetal abdominal circumference, you are right and you have
understood the most logical and accurate way of diagnosing UGR. To diagnose
the type of restriction (symmetric or asymmetric), proceed as in Exercise 6,
because if the gestational age was estimated through an early ultrasound, the
decision follows the lane for known gestational ages. f you answered the FAC/
FL ratio, later on in the text we will see that the effectiveness of this procedure
is not as good as the FAC, and it should be left for other situations.
DIAGNOSIS OF IUGR WHEN THE GESTATIONAL AGE
IS EITHER UNRELIABLE OR UNKNOWN IN PREGNANT
WOMEN CAPTURED LATE FOR CONTROL
When a pregnant woman seeks care late, the reliability of ultrasound to
estimate gestational age is hindered (the estimated spread in the 3rd.
trimester is + 2.5 or 3 weeks, depending on the measurement in question)
(Figure 4). n the absence of reliable data on gestational age as an
independent variable, it is impossible to fx a point on the x-axis. n this case,
you should use growth indicators that do not depend on gestational age.
Growth rate patterns based on the earlier value

This methodology is used to determine the increase of a certain fetal
measurement to be expected in a given period. Under these circumstances
one must refer directly to the ultrasound, as the measurement of the
2-week increase of the fundal height based on the previous value has a
low sensitivity (44%) (Specifcity 90%). Of all the fetal variables studied
by ultrasound, the rate of the fetal abdominal circumference growth as a
previous value (Figure 11) is the most effective parameter for diagnosis
(sensitivity 76%, specifcity 86%) (17).
Exercise 8
Case A
On a given date, the fetal abdominal circumference was measured and the
value obtained was 200 mm. Fourteen days later, the diagnostic procedure
was repeated, and this time the value was 230 mm. This means that in the
past two weeks, the perimeter increased 230-200 = 30 mm.
Plot this point in Figure 11, placing the point at the intersection of the 200
value of the X axis (abscissa) and the 30 value of the Y (ordinate), you
will notice that the point is located above the P50, which means that the
observed increase of the Fetal Abdominal Circumference is within the
normal range based on its previous value.
31
F
e
t
a
l

a
b
d
o
m
i
n
a
l

i
n
c
r
e
a
s
e

a
t

2

w
e
e
k
s
40
80 100 120 140 160 180 200 220 240 260 280 300 320 340
35
30
25
20
15
10
5
0
Previus value of the abdominal circumference
mm.
P
90
P
70
P
50
P
30
P
10
Figure 11: Growth rate of fetal abdominal circumference based on an
earlier value (17) confrm reference
Case B
Repeat the exercise with the following values:
1st. ultrasound measurement of the Fetal AC = 220 mm
2nd ultrasound measurement of Fetal AC
at two weeks =235 mm
Calculate the growth and plot it on Fig. 11. n this case you will notice that
the value obtained for the increase is below P10, so, unlike case A, the
fetus in case B is more likely to suffer from UGR.
Calculating the growth rate based on the previous value allows a better
diagnosis of the symmetric UGRs (sensitivity 94%) than asymmetric or
disproportionate UGRs (sensitivity 61%). Distance curves are also more
sensitive in symmetric UGRs.
The fetal abdominal circumference /femur length ratio
Another method to assess fetal growth independent of gestational age
is the fetal abdominal circumference / femur length ratio, which remains
constant, i.e. it has the same value between 20 and 40 weeks of gestation.
The discriminating point that best classifed the fetuses is percentile 10,
with a value of 4.25. Any value lower than 4.25 indicates a high probability
of asymmetric UGR. The sensitivity of this method for the diagnosis of
asymmetric UGR (decrease of the fetal abdominal circumference with a
constant femur length) is 74%.
Values equal to or greater than 4.25 correspond to normal fetuses (when
both values are normal), or a symmetric UGR (when both values are
low). This inability to discriminate between normal growth and symmetric
UGR reduces the diagnostic sensitivity of the latter to only 46%. The
specifcity for both restrictions is 90%.
t has been shown that based on its previous value, the fetal abdominal
circumference growth rate has a higher sensitivity for the diagnosis
of symmetric UGR, whereas fetal abdominal circumference / Femur
length ratio is more sensitive for asymmetric UGRs. Therefore, these
measures are not mutually exclusive but complementary. n summary
(Figure 10) the steps to monitor fetal growth include the use of distance
curves, whenever possible (known gestational age); otherwise, the fetal
abdominal circumference / femur length ratio needs to be determined. f
the latter value is less than 4.25, you must assume that the fetus has a
growth restriction, which is likely to be asymmetric.
f the ratio is greater than or equal to 4.25, the fetus may have an
appropriate growth or it could be a case of symmetric growth restriction;
the issue can be clarifed using the growth rate curves based on a previous
value and a new ultrasound examination. If the expected increase is
normal, the diagnosis is that of a fetus with normal growth. If, however,
the increase is less than expected, we are facing a growth restriction,
with high chances of being symmetric.
Sensitivity for the diagnosis of intrauterine growth restriction in case of
uncertain gestational age and late recruitment
33
Symmetric IUGR
Asymmetric IUGR
Abdominal
circumference
based on previous value
Abdominal
circumference/Femur
length ratio
94 %
61 %
46 %
74 %
Exercise 9
DIFFERENTIAL DIAGNOSIS BETWEEN A FETUS WITH
APPROPRIATE GROWTH AND IUGR WITH UNCERTAIN
LMP AND LATE CAPTURE
For this exercise you will use the algorithms for the differential diagnosis
between normal fetal growth and symmetric and asymmetric UGR
(page 25).
The exercise has a sequence such that the questions should be answered
as they are formulated. You should not go any further in your reading
without meeting this requirement.
Mrs. XX, (39 y) says she is in the last trimester of her pregnancy and
she has never attended antenatal care. She does not know the date of
her last menstrual period, because she was nursing a baby when she
became pregnant.
She reports having had 4 previous pregnancies; the last child born at
home weighed 2,100 g, in an apparently uneventful childbirth.
Below are the fndings of the general physical and obstetric examination
Mrs. XX
Maternal height
Gestational age
Current weight
Usual weight
Weight gain
Blood pressure
Fundal height
1.55 m.
Unknown
60 kg.
Unknown

140/94 mmHg
27 cm.
The abdominal palpation reveals that the fetus is in cephalic presentation and
that it is small in size.
What diagnoses would you suggest?
Macrosomic fetus (large)
Small fetus for < age or IUGR
None of the above
f you answered small fetus due to lower gestational age or UGR, you have
reasoned correctly, because it can be a pregnancy at an earlier gestational
age, and thus the fetus must be appropriate for that age, or it may be small
because it is growing less than expected. The obstetric behaviour may at times
be radically opposite (if it is a younger age the decision is to wait, while if it is a
full-term fetus with an UGR the pregnancy must be terminated), so.
How would you solve this problem?
I would estimate gestational age
asking about the date of onset of
the first fetal movements
I would assess fetal growth with
indicators independent from
gestational age
I would wait without doing anything
I would only estimate gestational
age by ultrasound

f you answered to only estimate gestational age by ultrasound, that was not
correct (pages 14 to 16), since in the last trimester the variability of the estimate
is + 2.5 weeks. That is, if they report 34 weeks, it may actually be 31.5 weeks
(34 - 2.5), or 36.5 weeks (34 + 2.5), and this is a considerable difference. The
woman's 27-cm fundal height is normal for 31.5 weeks and it is low for 36.5
weeks. Therefore, the doubt persists as to whether this fetus is SGA or UGR.
If you answered fetal growth assessment with independent indicators of
gestational age, you are on the right path, and you may continue
35
If the FAC/FL ratio was 4.25,
What would be your probable diagnosis?
Asymmetric IUGR or fetus with a normal growth
IUGR no matter what type
Certainty of fetus with a normal growth
Symmetric IUGR or fetus with a normal growth
f you answered symmetric UGR or fetus with normal growth, you were right.
Otherwise, see the algorithm on page 25 and read page 30 again.
f the ratio is less than 4.25 and the femur is abnormally long, this indicates that
the fetal abdominal circumference increased relatively less than the fetal femur,
a situation observed in asymmetric UGR (weight impairment with preserved
size).
Asymmetric IUGR = = < 4.25
Low fetal AC
Normal fetal femur length
Example = = 3.94
260 mm
66 mm
f the ratio is greater than 4.25, as in the case of this fetus (ratio 4.45),
the measurement of the fetal abdominal circumference or the fetal
femur length show proportionality. This may be either because the two
measurements are normal or because both are low.
Fetus with
normal =
growth
= > 4.25
Normal fetal AC
Normal fetal femur length
Example = = 4.55
300 mm
66 mm
Symmetric. IUGR = = > 4.25
Low fetal abdominal circumference
Low fetal femur length
Example = = 4.81
260 mm
54 mm
What test would you order to establish the differential diagnosis
between a fetus with a normal growth and an asymmetric IUGR,
two situations that require a radically different management?
Measure the FAC/FL ratio
Measure the increase of the FAC based on its previous value
Measure the Head Circumference
Measure the BPD

f you answered the fetal abdominal circumference measurement based on its
previous value, as shown by the ultrasound within a 14-day term, that is perfect
- you have understood the pathophysiology of fetal growth correctly. Otherwise,
re-read pages 30 to 32 and re-visit the algorithm on page 25.
The fetal abdominal circumference should be measured again within 1 or 2
weeks (ideally 2, whenever possible).
f the increase of the fetal abdominal circumference compared with its previous
value:
1) s the increase expected, the fnal diagnosis will be normal fetal growth
2) shows an increase that is less than expected, the fnal diagnosis will be
symmetric UGR
n the frst possibility, i.e., normal fetal growth, the woman is allowed to continue
with her pregnancy and in the second possibility with symmetric UGR, the fetal
vitality and lung maturity should be explored following a stepwise decision tree
that is applied in cases of UGR, as will be discussed later.

37
DIFFERENTIAL DIAGNOSIS BETWEEN SYMMETRIC IUGR
AND ERROR IN THE ESTIMATION OF GESTATIONAL AGE
BY LMP
Given the differences in the obstetric management and the confusions
it often leads to, it is important to note the differential diagnosis between
symmetric growth restriction and an error in the estimation of gestational
age by LMP.
Suspect miscalculation of amenorrhea based on the LMP, when:
x One measurement is below the normal range before 20 weeks. At
that gestational age the UGR is rarely expressed on the biparietal
diameter or head circumference, and much less likely on the waist
circumference
x The difference between gestational age calculated by LMP and
estimated by ultrasound is 2 weeks or multiples thereof, more
often, 4 weeks
x n the course of pregnancy the values measured by ultrasound
get gradually closer to normal. f it is a real UGR they get farther
apart. This is because the fetus is growing at a rate appropriate to
its true gestational age; hence, the younger the fetus, the faster
the growth rate
x The growth rate curves based on a previous value of DBP, fetal
abdominal circumference, etc., are normally increased. f the
increase observed is normal, it is highly likely that the fetus has
an appropriate growth. Conversely, if the increase is less than
expected, the most likely diagnosis is fetal growth slowdown
Table V describes the different alternatives that can be found using
distance curves and growth rates.
Table IV-Behavior of fetal growth when there is an error in the
estimation of gestational age by LMP and asymmetric
and symmetric growth restriction
CURVES
At a distance Growth rate based on a previous value
BPD
Head circumference
Femur length
AC
Normal Normal
Normal Decreased
Decreased Decreased
B.P.D
Head circ.
Femur length
AC
Error in the
estimation of
gestational age
Lower than
normal and tending
to converge
Lower than normal and diverging
Asymmetric IUGR
Symmetric IUGR
Within normal
ranges
may occur late
Lower than normal
and diverging
39
PROPOSALS FOR THE SOUND USE OF THE FETAL
GROWTH SURVEILLANCE METHODS
The association of fundal height in parallel with the mother's weight
gain during pregnancy (Table ), has a high sensitivity (75%) for
predicting SGA, surpassed only by the measurement of fetal abdominal
circumference as measured by ultrasound (94%).
The drawback of the association fundal height-mother's weight gain is the
high proportion of false positives 37% (complement to reach 100 of PPV, 100-
63 = 37%) which qualifes as a screening test, but never as a confrmation
test, since confrmation would lead to the adoption of decisions that may be
deleterious (termination of pregnancy in a fetus that is growing normally).
To monitor fetal growth, it is advisable to start collecting the risk factors
listed in Table and to monitor the course of fundal height and maternal
weight gain at each antenatal care visit.
The presence of risk factors, or abnormally low values of any of such
measures, makes it imperative to perform an ultrasound examination to
confrm or rule out the diagnosis (Fig. 12). A recent meta-analysis (25) has
shown that routine ultrasounds do not improve the detection of intrauterine
growth restriction when compared with the scan performed in cases where
there is a change in clinical parameters.
General population
14% SGA
N = 100
No SGA
86
SGA
14
Test Test +
Test + Test -
- -
True
11
False
23
+ +
True
63
False
3
True
10
False
0
+ +
True
23
False
1
- -
-
Prevalence 31%
34 66
24 10
Antenatal low
risk control
Intervention
is lost
Intervention
P.
de
d
e
t
e
c
t
i
n
Fundal
height
< P10
and/or
Weight gain
< P25
Referral for
Special exploration
P.
c
o
n
f
i
r
m
a
t
i
n
Ultrasound
Fetal
abdominal
circumf < P5
33
35 weeks
37
Aprox.
}
Figure 12 - Application of different tests to diagnose intrauterine growth
restriction. The frst step (screening) selected 34% of pregnant women. When
these undergo a confrmation test, the real IUGR can be detected
The predictive value of a test varies in according to the prevalence of the disease
to diagnose. n Table , the predictive positive value (PPV) of the association of
fundal height (FH) with weight gain is 63%. This predictive value was obtained
in a study that enrolled a population with a 38% prevalence of UGR.
The prevalence of intrauterine growth restriction in several hospitals in Latin
America is approximately 14%. Recalculating the positive predictive value for
the new prevalence of UGR, using Bayes' theorem, we obtain the following
fgures: for the fetal abdominal circumference = 100%, for fundal height or
maternal weight gain = 33%. This means that the false positives in this test
reach 67%. The high percentage of false positives seen with these screening
methods limit their validity for determining the population most likely to have the
disease. Positive cases should undergo a high-specifcity confrmation test such
as the ultrasound measurement of the fetal abdominal circumference.
This sequence of tests proposed in Figure 12 has a 79% diagnostic sensitivity
(Table V) which is lower than that achieved by routine ultrasound (94%) (Table
). But whereas in the latter case it is necessary to explore 100% of the pregnant
women with ultrasound, only one third of them (34%) would be explored with
this scheme, increasing the feasibility of its implementation.

Table V - Diagnosis of IUGR using risk factors, fundal height and
maternal weight gain as a screening procedure, and
ultrasound as a conhrmation procedure in a population
with a 14% prevalence of IUGR
NO
0 11
89
100
86
86
Yes
Yes 11
3
14
NO
D
I
A
G
N
O
S
I
S
IUGR
Sensitivity = 79% Test predictive Positive = 100%
Specifcity = 100% value Negative = 97%
The data that are processed in this Table V were obtained in studies
conducted by CLAP (24) and recalculated for a population of 100 pregnant
women with a 14% UGR.
{
41
OBSTETRIC MANAGEMENT OF INTRAUTERINE GROWTH
RESTRICTION
A) Antenatal management
1) General measures. Multiple interventions have been proposed to
reduce the risk of fetal growth restriction, but many of them are not
supported by good quality evidence. Measures like avoiding smoking
(35) and improving the woman's nutritional status with balanced calorie/
protein supplementation (34) administrating iron, folic acid (36) and other
micronutrients (37) and controlling maternal weight gain have proven
to be effective in the reduction of UGR. nstead, other interventions
such as psychosocial support during pregnancy (26), supplementation
exclusively with zinc (27), vitamin C (29), marine oils with prostaglandin
precursors (32), protein-rich diets (30, 31), maternal supplementation with
oral, parenteral or intra-amniotic nutrients (46), maternal bed rest (47),
treatment with beta-mimetics, calcium antagonists, oxygen therapy or
maternal blood volume expansion (48, 49, 50, 51) showed no signifcant
beneft in reducing the UGR.
ntermittent abdominal decompression for suspected fetal distress (33)
showed a signifcant increase in birth weight in the treated group, but
there is only one single study with just 56 cases.
2) Treatment of maternal diseases that affect fetal growth: pregnancy-
induced hypertension, chronic anemia, bleeding and diabetes, among
others.
In the case of hypertensive women, the administration of low doses of
acetyl salicylic acid (about 80 mg per day) during pregnancy signifcantly
decreased the prevalence of SGA in the group treated. These low doses
of aspirin reduce the production of thromboxane and to a lesser extent
of prostacyclin, with a predominance of the latter over the former, thus
favouring vasodilation. This would result in increased placental fow with
the consequent beneft to the fetus. At these doses no adverse effects
have been described in the mother, the fetus or the newborn. This
protective effect of aspirin would reduce the likelihood of SGA by 10%
(between 2 and 17%).
Table VI - Table VI: Prevention of the birth of small for gestational
age infants with low-dose aspirin. The common odds
ratio (summary measurement of the results of the 7
studies) shows the signihcant protective effect of its
administration. This protective effect of aspirin would
reduce the SGA likelihood by 20% (between 10% and
30%)
Therapy (%) (%) Odds ratio (95% confidence internval)
Contr.
4/48 Beaufils et al.
Wallenburg et al.
Wallenburg et al.
Schiff et al.
Uzan et al.
Sibai et al.
CLASP
Common
Odds ratio
4/41
4/30
2/34
19/156
69/1505
37/4810
473/6604
(8.3)
(1985)
(1985)
(1985)
(1985)
(1985)
(1985)
(1985)
0.08
0.09
0.03
0.05
0.18
0.56
0.79
0.71
0.24
0.37
0.11
0.26
0.37
0.78
0.92
0.81
1 0.01 10 0.1
0.77
1.41
0.36
1.29
0.73
1.08
1.06
0.92
(19)
(13.3)
(5.9)
(12)
(4.6)
(7.7)
(7.1)
13/48
9/23
16/27
6/31
20/73
88/1519
401/4821
553/6542
(28.8)
(39)
(59.2)
(19.4)
(27)
(5.8)
(8.3)
(8.5)
B) Childbirth
The health care professional frequently has to face the dilemma of having to
choose between the premature termination of pregnancy (risk of neonatal
death due to immaturity) or else to let it continue (risk of fetal death).
The response to these questions varies depending on the resources
available in the centers capable of offering higher complexity care, where
these pregnant women must be controlled.
f no special equipment to assess fetal health is available, the obstetric
management can be decided knowing the likelihood of fetal and neonatal
death according to the different gestational ages.
The obstetric decision should take into account the level of complexity of the
local neonatal care available; this circumstance is so important that it will
determine the gestational age at which you decide to interrupt pregnancy.
n a fetus under 26 weeks with UGR, one should try to do everything
possible to continue pregnancy "in utero, as that newborn is very likely
to die if birth occurs then. On the contrary, when it has reached 34 weeks,
43
the risk of fetal death begins to increase and becomes greater than the
risk of neonatal death, potentially leading to an indication of terminating
pregnancy. The period where it is diffcult to resolve what to do is the
interval between 26 and 33 weeks.
The best way to decide is to make sure one has the resources to monitor
the progress of fetal growth and vitality, and thus not to base one's
decision on statistics, but on the individual criteria, i.e., studying each
specifc case and adjusting the behavior as appropriate to that pregnancy.
If one has special resources to monitor fetal health, in addition to
gestational age and what caused that growth restriction (modifable factor:
hypertension, malnutrition, smoking; or non-modifable, genetic cause or
malformations) one should carefully address issues like the status of fetal
vitality, fetal lung maturity and its possible acceleration, together with the
course of development, especially once the corrective measures have
been implemented.
In preterm pregnancies, if the assessment of fetal vitality shows a fetus
in good conditions and the ultrasound shows that the fetus is growing,
pregnancy should go on. Otherwise if lung maturity and will interrupt
pregnancy. If the fetal lung has not synthesized surfactant, its synthesis
will need to be induced with glucocorticosteroids before terminating
pregnancy (Fig. 13).
IUGR
5 27 weeks 28 - 33 weeks 34 - 36 weeks
PuImonary maturation
ChiIdbirth - route to de seIected
based on obstetric status
US monitoring of growth every
1-2 weeks up to 34 weeks
US monitoring of growth
every 2 weeks up to
28 weeks
Negative Positive
P. confirmation
of fetaI damage
GestationaI age wiII be adjusted
based on the technicaI capabiIities
of the perinataI unit
* *
*
2 37 weeks
Treatment of specific conditions - Rest - Suppression of toxic agents - Diet adjustment
Arrest of growth
Yes No
Yes No
Repeat after
1 week
US controI
StimuIation of
Iung maturation
Figure 13-Flow chart showing the stepwise diagnostic decisions in
case of IUGR. (2)
f there are signs suggesting premature labor, uterine contractions must
be inhibited only in those cases where it is possible to strictly control fetal
growth and one can confrm that growth has not been arrested. The most
accurate parameter at this point to indicate the termination of pregnancy
is the arrest of fetal growth as shown by the ultrasound. f the fetus stops
growing, delaying the termination of pregnancy is associated with and
increased fetal mortality. Conversely, the interruption of pregnancy does
not worsen the neonatal prognosis.
CLAP's Fetal Health Unit found that fetuses presenting with UGR that
showed slowing of the growth of their abdominal circumference below
the 0.5 percentile were more likely to die in utero or within the frst 24
hours of life. By contrast, fetuses diagnosed with UGR but with abdominal
circumference values within the areas corresponding to the top 5 percentile
and lowest 0.5 percentile (Fig. 14) the probability of dying drops, so if the
gestational age is less than 33 weeks, pregnancy may continue with a
strict monitoring of fetal growth.
P
50
P
5
Abdominal
circumference
390
370
350
330
310
290
270
250
230
210
190
170
150
130
110
90
70
15 17 19 21 23 25 27 29 31 33 35 37 39 41
Weeks of amenorrhea
Ar ea of
al ar m
Zone w i t h
hi gh deat h
odds
Figure 14-Normal pattern of fetal abdominal circumference growth
with alarm zone and zone of high probability of death.
45
Several diagnostic procedures have been used to assess fetal vitality; many
of them have shown signifcant faws (false positives and negatives) that
make them useless for the purpose intended, including: a) frequency of
fetal movements (38); b) the serial antepartum fetal cardiotocogram (39);
and c) the fetal biophysical profle. (40). Other procedures such as d) serial
ultrasound assessments evaluating the fetal measurements and functional
elements (amniotic fuid) (41, 42) and e) the Doppler of the fetal and placental
arteries has shown good effcacy in the evaluation of fetal health.
Serial ultrasound studies are an essential tool for monitoring fetal well-
being and to determine whether growth continues to deteriorate or if, on
the contrary, it recovers its growth pace and exceeds the lowest level in the
normal patterns, succeeding to catch-up or recuperating growth.
The measurement of the amniotic fuid volume through various techniques
permits to identify oligohydramnios, a condition that - in the case of UGR
- is linked to fetal oliguria resulting from the adaptive redistribution of blood
fow. Depending on its severity, this should be seen as a warning sign for
termination of pregnancy.
The frequency of monitoring fetal growth is an important issue that needs
to be addressed. As has already been mentioned, performing ultrasound
scans at intervals of less than 1 week may increase the frequency of false
positives (43); consequently, the ideal interval is every 2 weeks, which allows
for a more adequate evaluation of growth rate.
The blood fow Doppler patterns of the placental and fetal arteries are a sign
of fetal adaptation to stressful situations (44). The fetal and fetal-placental
Doppler performed to high-risk pregnant women has shown a reduction
both of perinatal mortality and unnecessary obstetric interventions (45).
The Doppler investigation of the shape of the fow rate wave can provide
useful information. Changes in the values of the different indices employed
(Resistance, pulsatility, S/D) evidenced during the exploration of the fetal
vessels, refect the redistribution of blood fow in response to fetal hypoxia.
n the umbilical artery, the fetal aorta, and the renal, iliac and femoral arteries,
the ratios are increased, refecting an enhanced resistance to blood fow,
whereas in the carotid and middle cerebral arteries the ratios are reduced,
indicating a greater blood supply to the brain. Some authors report that when
this compensatory mechanism is missing, or when the resistance of the
middle cerebral arteries is increased, the prognosis of the fetus is dire.
The utero-placental arteries (arquate arteries of the uterus) show an
increased resistance to blood fow, mainly when the cause of the restriction
is a vascular disease in the mother.
According to some authors, the abnormal patterns of the fow rate wave
showing fetal impairment can already be observed from 1 to 26 days
before they can be detected through an abnormal cardiotocography and
they also have a better sensitivity and specifcity (30).
A pattern that deserves attention is when the umbilical artery fow cannot
be seen in diastole, or when there is no back-fow. This pattern has been
associated with severe fetal compromise such as acidosis and hypoxia
confrmed by cordocentesis. The risk of fetal mortality for these two situations
is 4 to 10 times higher than when the diastolic fow is present (30).
The increased resistances in the middle cerebral artery are also elements
of a poor prognosis requiring an active obstetric behavior for terminating
pregnancy (45) (21).
Unfortunately, these tests were incorporated into clinical practice without
having completed their validation process, which limits their scope and the
interpretation of their results. None of these tests alone should determine
management, but they are elements that enrich the decision-making process.
C) During labor
The route chosen to terminate pregnancy should be discussed on a case
by case basis, but the caesarean section is usually the strategy of choice
when there is evidence of severe fetal impairment (53).
In cases where the plan is to have a vaginal delivery, one must consider
that these fetuses show a high incidence of acute fetal distress, especially
the asymmetric type of UGR, so it is recommended to ensure a strict
clinical monitoring of the fetal heart rate and uterine contractions during
labor. Continuous electronic monitoring and the eventual acquisition of
a fetal capillary blood sample to study the acid-base balance can be of
great help for the management of these cases (54).
Exercise 10
Mrs. XX in Exercise 9 comes back to you two weeks after the frst scan
(the gestational age was then diagnosed as 30 2.5 weeks).
She comes with an ultrasound performed 14 days after the frst; this
new ultrasound reports that the increase in the abdominal circumference
value is consistent with the earlier ultrasound.
47
Based on this information your diagnosis would be:
Symmetric IUGR
Your diagnosis is:
Asymmetric IUGR
f you believe that this baby has a normal growth, your reasoning was adequate.
f you made a diagnosis of UGR of some sort, re-read pages 16 to 25.
The woman continues with her obstetric control and at 35 weeks gestation they
fnd that the UH has remained arrested at 27 cm, with a 400g weight gain. n this
context you suspected UGR and request an ultrasound, which reports:
35 week fetus; GA based on the previous ultrasound
Abdominal circumference
280 mm (<P5)
319
69 mm
Head circumference
Femur length
Reduced amniotic fluid

Use the head circumference (Fig. 8) and abdominal circumference (Fig. 9)
charts and record the course of fetal growth.
Symmetric IUGR
What is your diagnosis?
Asymmetric IUGR
but genetically small
f your answer is asymmetric UGR, you are well oriented. t is a case of UGR
because fetal growth is below the 5th percentile for gestational age. t is
asymmetric because the fetal abdominal circumference / femur length ratio is
4.05 (i.e., less than 4.25), which shows a reduction in waist circumference, but
not a reduction in the femur length.
The fetus has been confrmed an asymmetric UGR. What monitoring
strategy would you suggest?
The fetus has been confirmed an asymmetric IUGR.
What monitoring strategy would you suggest?
Monitoring with biophysical profile of the fetus
Monitoring only with fetal eco Doppler
Monitoring only with fetal eco Doppler ultrasound
Monitoring with measurement of the fundal height
Monitoring only with obstetric ultrasound
If your answer was to monitor with eco Doppler and ultrasound your choice
was correct, because the ultrasound will allow you to assess whether the
fetus recovers its growth rate (catch up) and the eco Doppler will identify the
fetal response to the stress it is exposed to and to establish the right timing to
terminate that pregnancy for the sake of the fetus. You request an ultrasound
and an echo Doppler and you schedule a visit.
The eco Doppler received at the new visit reports: umbilical artery: absence of
diastolic fow during diastole. Middle cerebral artery: P below the 5th percentile.
You decide
Schedule a new follow-up visit in 1 week
You would admit her to rest at the hospital to
promote the fetal catch up
Terminate pregnancy
If you opted for termination of pregnancy, you have made the right decision.
49
EXERCISES USING THE PERINATAL COMPUTING
SYSTEM FOR THE ASSESSMENT AND MONITORING OF
FETAL GROWTH
The computer software in the Perinatal nformation System (SP2010) offers
several options to assess and monitor fetal growth.
As discussed below, the programs that can be used to this aim are:
Selection by variables
Distribution of a variable
Listing of Medical Records
Reports of basic indicators
Risk Estimation
This exercise is expected to strengthen local planning and evaluation of activities,
and contribute to epidemiological surveillance of fetal growth.
Weight by gestational age
To determine the percentiles of weight for each week of amenorrhea, SP2010
uses the program Distribution of a variable.
First you must defne the population under study. This will require the selection
of singleton pregnancies with live births and weights equal to or greater than
500 grams. This selection is done using the Selection by variables.

After completing the selection based on the variables established, using the
program Distribution of a variable we put Gestational age at birth as
a distribution variable (independent) and birth weight as a study variable
(dependent).
The following report is obtained for the institution A:

In the previous window, as we position ourselves at each gestational age,
the program calculates the birth weight percentiles for the infants born with
that gestational age selected. n the fgure we see that for the 34 weeks of
gestation, the 10th and 90th percentiles for birth weight are 1,630 g and
2,896 g respectively.
51
Between weeks 34 and 40, we obtained the following values for percentiles 10 and 90
3
4
A- Go to the following fgure. Note that it shows a chart of weeks of
amenorrhea and weight in grams. The two points that have been marked
correspond to the values of percentiles 10 and 90 for
34 weeks.
Complete the fgure by placing each of the two percentiles (10 and 90) in the
following weeks, taking them from the table above. Once the transcription has
been completed, draw a continuous line to connect the points corresponding
with percentiles 10 and another one with percentiles 90.
5000
4000
3000
2000
1000
G
r
a
m
s
P
90
P
10
Amenorrhea in weeks
25 27 29 31 33 35 37 39 41
Newborns weight in grams
Weeks p10 p90
34 1630 2896
35 1870 2980
36 1954 3090
37 2265 3390
38 2480 3490
39 2588 3590
40 2670 3700
Now we will repeat the same exercise, but in this case for a selected
subpopulation that belongs to Institution B. Using the Selection by
variables tool, select the population that meets the following conditions:
x Singleton pregnancy and
x Live newborn
x Birth weight equal to or greater than 500 grams
x No maternal morbidity
x Non-smoking mother
x Literate mother
x Five or more antenatal visits
The selection will look as in the fgure below
Once the selection of the variables set has been completed, we use the
program Distribution of a variable and place the Gestational age
at birth as a variable for distribution, and birth weight as a study
variable.
53
The result is shown in the following screen
We draw a table similar to that used in the previous example, but
for this new target population, we have
Weeks p10 p90
34 1810 3220
35 2250 3250
36 2480 3290
37 2580 3590
38 2750 3766
39 2894 3930
40 2990 4060
Newborns birth weight in grams
Plot the values of percentiles 10 and 90 of this subpopulation of nstitution
B on the same axes. Use a cross instead of the point used previously and
connect them with a dashed line.
Compare both distributions and check the correct options in the list below
Both patterns are the same
The 10th percentile is higher in the selected population
The 90th percentile is higher in the selected population
Which do you think best represents the growth potential?
The population in Institution A
The population selected in Institution B
You may have noticed that the number of cases (N) used to calculate
percentiles varies in accordance with the number of restrictions in the
selection of the study population. The more restrictions, the lower the
number of cases.
n the cases where there are diffculties, what would be the best
alternatives to calculate percentiles in these cases?
x Prolonged study
x Sum with other similar institutions
55
Now draw the weight distribution of the Population of the Institution B
selected based on the standards published by CLAP described in the
fgure below.
Until your institution has its own patterns to classify the newborns, it is
right to choose the curve developed by CLAP.
Yes No
Amenorrhea in weeks
G
r
a
m
s
Listing of medical records
historias
B- The SP2010 software lets you list a set of medical records that meet
certain conditions. In each list, the software displays a document that
lists medical records selected by the selection condition and a number
of variables that can be chosen by the operator. Using this option, in the
fgure below we can see a sample of 36 newborns from Institution A,
with birth weight and gestational age data.
57
Locate one by one the weights of the newborns in the patterns drawn
on the fgure used to plot the percentiles 10 and 90 of the populations
studied. Count how many small for gestational age (SGA) newborns
are identifed if the cutting point used is the 10th percentile of birth weight
by gestational age taking as a reference the pattern built with:

SGA
1) The sample of nstitution A with singleton pregnancies N %
2) The sample selected of nstitution B with
singleton pregnancies N %
The fgure below shows the points of the table that have been plotted in
the curve developed by CLAP / WRH.
3) dentify:
a) How many SGAs do you diagnose? N %
b) How many LBWs (<2500g) do you diagnose? N %
Amenorrhea in weeks
G
r
a
m
s
You've seen that the number of LBW is not similar to that of the SGAs
diagnosed.
Tick the option that best accounts for the difference.

The fact that they are singletons
They result from different concepts
Complete the following table with the results obtained
Reference pattern
Population selected
of Institution A
Population selected
of Institution B
CLAP
Number of SGAs
diagnosed
Risk estimations
C- The program on Risk estimation used in the following examples is
an option that allows you to cross any 2 variables of the perinatal medical
record - one as a variable of exposure and the other as an adverse result
- and to obtain relative risks (RR) with their corresponding confdence
intervals.
The tables below show the relative risks (RR), their confdence intervals
and Population Attributable Risk (PAR) of these 4 factors: history of LBW,
smoking habit, pre-eclampsia and multiple pregnancy of a population
of live births that excluded those weighing less than 500 grams. The
outcome used to indicate damage (abnormal results) was Small for
Gestational Age (SGA).
59
History of LBW
Smoking habit
Preclampsia
Multiple pregnancy
61
Fill in the chart below with the data included in the table
Damage: SGA
Proportion
exposed
(frequency %)
Risk Factors
RR
PAR
%
History of LBW
95% Confidence
interval
Smoking habit
Pre-eclampsia
Multiple pregnancy
Analyze the picture
1) dentify the risk factor most commonly associated with SGA
2) dentify the risk factor whose control would have more impact on
reducing the frequency of SGAs
3) dentify the factors that are easier to control
4) Of the 4 risk factors listed herein, select the ones whose approach you
think are a priority and explain why
...
..................................................................................................................
5) Propose a specifc action on the factors that you have chosen
...
..................................................................................................................
Basic statistics
D- The Key Indicators Report program provides the main indicators
of perinatal care and gives a clear overview of some characteristics of the
population served and the outcomes of the care provided.
On the Basic Statistics tag you will get the Early Neonatal Mortality
Rate, while in the Newborn tag in the birth weight and weight by
gestational age reports you will obtain the appropriate data for SGA,
LBW and VLBW.
To obtain information by periods, you must select them in the option
Selection by Dates. The following illustrates the selection of the frst
trimester of 2008.
63
Proceeding this way, the following information was obtained by trimesters
for the percentage of Small for Gestational Age (SGA), low birth weight
(LBW) (<2500 g) and very low birth weight (VLBW) (<1500 g) and early
neonatal mortality rate (ENMR) over 500g. Complete the following
information from the four consecutive trimesters of year 2008 of the
nstitution B in the table below these reports.
First trimester
Second trimester
65
Third trimester
Fourth trimester
67
Trimester ENM rate %o SGA %
1
2
3
4
LBW %
VLBW %
Tendencia en a
disminuir en el ao
SI NO
T a s a
MNP %o
PEG %
BPN %
M B P N
%
Analyze the trend of these indicators and tick the correct choices
YES NO
ENM rate %
SGA %
LBW
VLBW%
Tendency to be reduced
during the year
Answers to the exercises using the perinatal information
system for the assessment and monitoring of fetal growth
Exercise A - Weight percentiles of Institution A
Weight percentiles at Institution B
G
r
a
m
s
G
r
a
m
s
Weeks of amenorrhea
Weeks of amenorrhea
69
Weight percentile of nstitution A (._.) and B (-x-x-)
Compare both distribution and check the correct choices in the list below
Both patterns are the same
Percentile 10 is higher in the selected population
Percentile 90 is higher in the selected population
Which do you think best represents the growth potential?
The population of Institution A
Population selected from Institution B
You could see that the number of cases (N) used to calculate percentiles
varies with the number of restrictions in the selection of the study
population.
What would be the best alternatives to calculate percentiles in the cases
where there are diffculties?
Prolonged study
Adding the cases with other similar institutions
G
r
a
m
s
Weeks of amenorrhea
Now draw the weight distribution of the "Population selected in Institution
B over the standards published by CLAP found in the fgure below.
Until your institution has its own standards to classify newborns it is right
to choose the curve developed by CLAP
Yes No
Exercise B - One by one distribution of the weights of the 36 newborns
according to the standards used by institutions A and B and those
developed by CLAP/WR
Institution A
G
r
a
m
s
Weeks of amenorrhea
G
r
a
m
s
Weeks of amenorrhea
71
Institution B
Small for gestational age using the 10th percentile of birth weight by
gestational age as a cut-off point, taking the standards made with the
following as a reference:
The sample of nstitution A with singleton pregnancies N 3 % 8.3
The sample selected from nstitution B N 5 % 13.8
The standards defned by CLAP/WR N 4 % 11.1
How many LBWs (<2500g) are diagnosed
the CLAP/WR standards N 3 % 8.3
G
r
a
m
s
Weeks of amenorrhea
G
r
a
m
s
Weeks of amenorrhea
You have seen that the number of LBWs is not similar to that of SGAs
diagnosed. Tick the option that best accounts for the difference.
The fact they are singletons
They are the result of different concepts
Complete the following table with the results obtained
Reference pattern
Population selected
of Institution A
Population selected
of Institution B
CLAP
4 5 3
Number of SGAs
diagnosed
Exercise C.
Damage: SGA
Proportion
exposed
(frequency %)
Risk Factors
RR
PAR
%
History of LBW
95% Confidence
interval
Smoking habit
Pre-eclampsia
Multiple pregnancy
13.63
12.47
13.60
18.61
1.94
2.39
2.05
3.11
1.58 - 2.37
2.17 - 2.63
1.74 - 2.41
2.68 - 3.61
3.17
17.44
4.51
4.73
1) Multiple Pregnancy
2) Smoking habit
3) Smoking habit
4 and 5) Plenary
Exercise D
Trimester ENM rate %o SGA %
1
2
3
4
4.4
3.5
5.1
5.0
5.5
6.2
6.1
5.5
8.3
8.9
8.7
8.5
1.1
1.3
1.1
1.3
LBW %
VLBW %
YES NO
ENM rate %
SGA %
LBW
VLBW%
Tendency to be reduced
during the year
73
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www.cl ap.ops-oms.org
Monitoring

Fetal
Growth
Self - Instruction
Manual
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Sci ent i f i c Publ i cat i on CLAP/WR 1586.02 2011
2nd edition
Lat i n Ameri can Cent er for Peri nat ol ogy
Women & Repr oduct i ve Heal t h - CLAP/WR

Monitoring Fetal Growth

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