IUGR & IUFD

DR. SALWA NEYAZI

CONSULTANT OBSTETRICIAN GYNECOLOGIST
PEDIATRIC & ADOLESCENT GYNECOLOGIST
 IUGR

What is the definition of IUGR?

•< 10th centile for age  include normal fetuses at the

lower ends of the growth curve + fetuses with IUGR
This definition is not helpful clinically

•< 5th centile for age 

•< 3rd centile for age the most appropriate definition but
associated with adverse perinatal outcome
 ?What is the deference between IUGR & SGA

SGA  < 10th centile for the population, which means it is

at the lower end of the normal distribution ie.
Constitutionally small but have reached their full growth
potential

IUGR Failure of the fetus to chieve the expected weight

for a given gestation
 ?What are the causes of IUGR

•Maternal medical conditions •1ry placental disease

•Chromosomal anomalies & •Extremes of maternal age

aneuploidy
•Low socioeconomic
•Genetic & Structural anomalies status

•Exposure to drugs & toxins •Infections

•Multiple gestation
Which maternal medical conditions result in IUGR?

•HPT
•PET
•DM with vascular involvement
•SLE
•Anemia
•Sickle cell disease
•Antiphospholipid syndrome
•Renal disease
•Malnutrition
•Inflammatory bowel disease
•Intestinal parasites
•Cyanotic pulmonary disease
?How does the placenta play a role in the development of IUGR

•Abnormalities in placental development & trophoblast

invasion Idiopathic or due to maternal disease eg
SLE, PET, DM, HPT
•Chronic partial abruption
•Placental infarcts
•Placenta previa
•Chorioangioma
•Circumvallate placenta
•Placental mosaicism
•Twin to twin transfusion Syndrome
?What infections result in IUGR
of IUGR 5-10%

Congenital infections:
•CMV
•Rubella
•Herpes
•Vericella zoster
•Toxoplasmosis
•Malaria
•Listeriosis
Which drugs can result in IUGR?

•Alcohol
•Cigarette smoking 3-4X
•Heroin & coccaine
•Methotrexate
•Anticonvulsants
•Warfarin
•Antihypertensives /ß-blockers
•Cyclosporin
What are the genetic disorders that can result in IUGR?

of IUGR 15% Features suspicious of trisomy

•Down’s syndrome T21 •Symmetric IUGR

•Trisomy 13,18 •AFV/ Doppler N
•Turner syndrome •Structural abnormalities
•Neural tube defects •Maternal age
•Achondroplasia •Nuchal translucency
•Osteogenisis imperfecta •Biochemical screening results
•Abdominal wall defects
•Duodenal atresia
•Renal agenesis/ Poter’s S
?Why does multiple pregnancy result in IUGR

•Placental insufficiency /inadequate placental

reserve to sustain N growth of > one fetus
•Twin to twin transfusion syndrome
•Anomalies
 with higher order gestations
 monozygotic twins
 ?What are the types of IUGR

1-Symmetric –20%

•Proportionate decrease in many organ weights including

the brain

•Deprivation occurs early

•The fetus is more likely to have an endogenous defect that

preclude N development

•U/S biometry  All measurements BPD, FL, AC  

 Types of IUGR
2-Asymmetric IUGR—80%

•Relative sparing of the brain

•Deprivation occurres in the later half of pregnancy

•The infant is more likely to be N but small in size due to

intrauterine deprivation

•U/S biometry BPD, Fl  N, AC  

?Why IUGR often associated with olighydramnios

 blood flow to the lungs  pulmonary

contribution to amniotic fluid volume

blood flow to the kidneys GFR

urine output

It is present in 80-90% of IUGR fetuses

 How to evaluate a case of IUGR?
1-History:
•Current preg
 LMP, preg test, quickening
 APH, abruptio placentae, & fetal movements
•Previous obstetric Hx particularly looking for IUGR,& adverse
outcome
•Medical Hx: connective tissue diseases, thrombotic events &
endocrine disorders
•Hx of recent viral illness
•Drug Hx
•Family Hx of congenital abnormalities & thrombophilias
 EXAMINATION

•Symphysis fundal height in cm = gest age in wks after 24 wk

•Sensitivity 46-86% in detecting IUGR
•A difference of more than 2cm requires fetal assessment
•Oligohydramnious may be detected on palpation

U/S

•Fetal biometry for dating then serial measurements

•Anomaly scan
•AF index
•Doppler umbilical artery resistance index, MCA
•Repeat tests every1-2 wks
 Invasive fetal testing

•Amniocentesis or placental biopsy/ fetal blood sampling

for karyotyping if aneuploidy is suspected
for viral studies if infections suspected
•Caries the risks of  infection, PROM, Preterm labor

Retrospective tests

•Maternal blood tests for  CMV, Rubella, Toxo

Metabolic disorders
thrombophilia
•Placenta should be sent for HP
•Postmortem examination
 The constitutionally small fetus

•A fetus growing parallel to the lower centiles through out preg

•Anatomically N
•AFV N
•Doppler N
•Slim petite women
 Complications of IUGR

•Maternal complications due to underlying disease

 risk of CS
•Fetal complications Stillbirth, hypoxia/acidosis,
malformations
•Neonatal complications Hypoglycemia, hypocalcemia,
Hypoxia & acidosis, hypothermia, meconium aspiration ,
Polycythemia, hyperbilirubinemia, sepsis, low APGAR score
congenital malformations, apneic spells, intubation
sudden infant death syndrome
•Long term complications Lower IQ, learning & behavior
Problems, major neurological handicap seizures, cerebral
Palsy, mental retardation, HPT
•Perinatal mortalility 1.5-2X
 Treatment

•Stop smoking / alcohol

•Bed rest  uterine blood flow for pt with asymmetric IUGR
•Low dose aspirin
•Weekly visits attention to : FM, SFH, maternal wt, BP, CTG,
AFV
•U/S every 2-4 wks
•BPP
•Contraction stress test
•Delivery 38 wks or earlier if there is fetal compromise
•Glucocorticoids if planing delivery before 34 wks
•Close monitoring in labor/ continuous monitoring /scalp PH
•CS may be necessary
 IUFD

Definition: dead fetuses or newborns weighing > 500gm

Or > 20 wks gestation
total births 1000 /4.5

Diagnosis
Absence of uterine growth
Serial ß-hcg
Loss of fetal movement
Absence of fetal heart
Disappearance of the signs & symptoms of pregnancy
X-ray Spalding sign
Robert’s sign
U/S 100% accurate Dx
 Causes OF IUFD Maternal 5-10%
•Antiphospholipid antibody
•DM
Fetal causes 25-40% •HPT
•Chromosomal anomalies
•Trauma
•Birth defects
•Abnormal labor
•Non immune hydrops
•Sepsis
•Infections
•Acidosis/ Hypoxia
Placental 25-35% •Uterine rupture
•Abruption
•Postterm pregnancy
•Cord accidents
•Drugs
•Placental insufficiency
•Thrombophilia
•Intrapartum asphyxia
•Cyanotic heart disease
•P Previa
•Epilepsy
•Twin to twin transfusion S
•Severe anemia
•Chrioamnionitis
Unexplained 25-35%
 A systematic approach to fetal death is valuable in
determining the etiology
B-Maternal History
History-1 I-Maternal medical conditions
•VTE/ PE
A-Family history •DM
•Recurrent abortions •HPT
•VTE/ PE •Thrombophilia
•Congenital anomalies •SLE
•Abnormal karyptype •Autoimmune disease
•Hereditary conditions •Severe Anemia
•Developmental delay •Epilepsy
•Consanguinity
•Heart disease
II-Past OB Hx
•Baby with congenital anomaly / hereditary condition
•IUGR
•Gestational HPT with adverse sequele
•Placental abruption
•IUFD
•Recurrent abortions
 History-1
Specific fetal conditions
•Nonimmune hydrops
Current Pregnancy Hx •IUGR
•Maternal age •Infections
•Gestational age at fetal death •Congenital anomalies
•HPT •Chromosomal abnormalities
•DM/ Gestational D •Complications of multiple gestation
•Smooking , alcohol, or drug abuse
•Abdominal trauma
•Cholestasis
Placental or cord complications
•Placental abruption
•Large or small placenta
•PROM or prelabor SROM •Hematoma
•Edema
•Large infarcts
•Abnormalities in structure , length or
insertion of the umbilical cord
•Cord prolapse
•Cord knots
•Placental tumors
 2-Evaluation of still born infants
Infant desciption Placenta
•Malformation •Weight
•Skin staining •Staining
•Degree of maceration •Adherent clots
•Color-pale ,plethoric •Structural abnormality
Umbilical cord •Velamentous insertion
•Prolapse •Edema/ hydropic changes
•Entanglement-neck, arms, ,legs Membranes
•Hematoma or stricture •Stained
•Number of vessels •Thickening
•Length
Amniotic fluid
•Color-meconium, blood
•Volume
 Investigations-3
Maternal investigations
•CBC
•Bl Gp & antibody screen
•HB A1 C
•Kleihauer Batke test
•Serological screening for Rubella
•CMV, Toxo, Sphylis, Herpes &
Parovirus
•Karyotyping of both parents (RFL,
Baby with malformation
•Hb electrophorersis
•Antiplatelet anbin tibodies
•Throbophilia screening (antithrombin
Protein C & S , factor IV leiden,
Factor II mutation, , lupus
anticoagulant,
anticardolipin antibodies)
•DIC
Fetal inveswtigations
•Fetal autopsy
•Karyotype
spcimen taken from cord(
,blood, intracardiac blood
,body fluid, skin, spleen
Placental wedge, or amniotic
)Fluid
•Fetography
•Radiography
Placental investigations
•Chorionocity of placenta in
twins
•Cord thrombosis or knots
•Infarcts, thrombosis,abruption,
•Vascular malformations
•Signs of infection
•Bacterial culture for Ecoli,
.Listeria, gp B strpt
 IUFD complications

•Hypofibrinogenemia  4-5 wks after IUFD

•Coagulation studies must be started 2 wks after IUFD
•Delivery by 4 wks or if fibrinogen < 200mg/ml
 Psychological aspect & counseling

•A traumetic event
•Post-partum depression
•Anxiety
•Psychotherapy
•Recurrence 0-8% depending on the cause of IUFD