Intrauterine Growth Restriction

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Chapter 213 Intrauterine Growth Restriction

INTRODUCTION

Description: Intrauterine growth restriction is symmetric or asymmetric reduction in the size and weight of the growing fetus in utero, compared with that expected for a fetus of comparable gestational age. This may occur for many reasons, but most occurrences represent signs of significant risk of fetal death or jeopardy to the fetus. Some authors advocate identifying fetuses with growth between the 10th and 20th percentiles as suffering “diminished” growth and at intermediate risk for complications.
Prevalence: Problems of consistent definition make estimates difficult; by most definitions 5% to 10% of pregnancies.
Predominant Age: Reproductive; higher at the extremes of childbearing. (For women younger than age 15 the rate of low birthweight is 13.6% compared with 7.3% for women between 25 and 29 years of age. When multiple gestations are excluded, the rate for women older than age 45 is greater than 20%.)
Genetics: No genetic pattern.

ETIOLOGY AND PATHOGENESIS

Causes: Idiopathic (50%). Maternal disease—hypertension; drug or alcohol use; smoking; Dilantin (phenytoin), coumarin, propranolol, or steroid use; poor nutrition, inflammatory bowel disease, low maternal weight (<50 kg), high altitude, hemoglobinopathy, cyanotic heart disease, multiple pregnancy, irradiation. Placental disease or abnormalities—placenta previa, fibrosis, chronic infection, partial abruption or infarction. Fetal factors—congenital anomalies, chromosomal factors, chronic fetal infections.
Risk Factors: Chronic maternal disease (hypertension, renal disease, cardiovascular disease), impaired placental function, congenital anomalies, history of recurrent abortion, fetal death, or preterm labor.

CLINICAL CHARACTERISTICS

Signs and Symptoms

• Uterine size less than dates
• Oligohydramnios
• Fetal growth that falls below the 10th percentile for gestational age or demonstrates reduced growth velocity on serial examinations

DIAGNOSTIC APPROACH

Differential Diagnosis

• Inaccurate gestational age
• Congenital anomalies
• Multiple gestation
• Constitutionally small infants (small for gestational age [SGA])
• Extrauterine gestation

Associated Conditions: Prematurity, intrauterine fetal death, congenital anomalies, and oligohydramnios.

Workup and Evaluation

Laboratory: No evaluation indicated unless suggested by maternal disease.
Imaging: Ultrasonography with fetal biometry compared with curves specific to the location and population served. The diagnosis must also be based on serial examinations that provide information about the growth of the individual fetus.
Special Tests: When found in advanced gestations: fetal nonstress and contraction stress testing or biophysical profiling. The role of Doppler flow studies continues to be evaluated.
Diagnostic Procedures: Physical examination, ultrasonography. (Physical examination may miss up to two thirds of cases; ultrasonography can exclude or verify growth restriction in 90% and 80% of cases, respectively.) Intrauterine growth restriction must be distinguished from infants who are constitutionally small for gestational age who are not at increased risk. Asymmetric restrictions in growth argue against a constitutional cause. Early intrauterine insults are more likely to result in symmetric growth restriction; later insults result in asymmetry. Similarly, intrinsic factors generally cause symmetric restriction; extrinsic factors generally cause asymmetric restriction.

Pathologic Findings

Reduced fetal fat stores and reduced overall size compared with that expected for gestational age.

MANAGEMENT AND THERAPY

Nonpharmacologic

General Measures: Evaluation, ultrasonography with biometry. Cessation of tobacco and alcohol use (if present).
Specific Measures: Based on cause and stage of gestation. Early delivery is often necessary. (The majority of fetal deaths occur after 36 weeks of gestation.) Constitutionally small infants require no intervention.
Diet: No specific dietary changes indicated unless deficiencies identified.
Activity: No restriction except as dictated by maternal disease or fetal condition.
Patient Education: American College of Obstetricians and Gynecologists Patient Education Pamphlet AP098 (Special Tests for Monitoring Fetal Health), AP025 (Ultrasound Exams).

Drug(s) of Choice

None. (Low-dose aspirin therapy has been advocated but has yet to be firmly established in its efficacy or role in management.)

FOLLOW-UP

Patient Monitoring: Enhanced fetal assessment, antenatal fetal testing (including nonstress testing, biophysical profiles, and contraction stress tests). Patients at risk because of maternal disease should have early assessment of fetal growth (biparietal diameter, head circumference, abdominal circumference, and femur length) with frequent remeasurement as the pregnancy progresses. This may need to be done as often as every 2 to 3 weeks in severe cases. Careful fetal monitoring during labor.
Prevention/Avoidance: Management of maternal disease.
Possible Complications: Progressive deterioration of fetal status and intrauterine fetal demise. (There is an 8- to 10-fold increase in the risk of perinatal mortality; growth restriction is the second most important cause of perinatal morbidity after preterm delivery.) Long-term physical and neurologic sequelae are common. The risk of adverse outcome is generally proportional to the severity of growth restriction present. The presence of risk factors for intrauterine growth restriction increases the risk of fetal death by 2-fold in growth-restricted fetuses. The most immediate fetal morbidities are birth asphyxia, meconium aspiration, sepsis, hypoglycemia, hypocalcemia, hypothermia, polycythemia, thrombocytopenia, and pulmonary hemorrhage.
Expected Outcome: With early detection, progressive fetal growth can often be achieved, although many pregnancies may require early delivery or other interventions to ensure fetal well-being.

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MISCELLANEOUS

ICD-9-CM Code: 656.5.

REFERENCES

Level I

Larsen T, Larsen JF, Petersen S, Greisen G. Detection of small-for-gestational-age fetuses by ultrasound screening in a high risk population: a randomized controlled study. Br J Obstet Gynaecol. 1992;99:469.

McCowan LM, Harding JE, Roberts AB, et al. A pilot randomized controlled trial of two regimens of fetal surveillance for small-for-gestational-age fetuses with normal results of umbilical artery Doppler velocimetry. Am J Obstet Gynecol. 2000;182:81.

McKenna D, Tharmaratnam S, Mahsud S, et al. A randomized trial using ultrasound to identify the high-risk fetus in a low-risk population. Obstet Gynecol. 2003;101:626.

Level II

Leitich H, Egarter C, Husslein P, et al. A meta-analysis of low dose aspirin for the prevention of intrauterine growth retardation. Br J Obstet Gynaecol. 1997;104:450.

Oken E, Kleinman KP, Rich-Edwards J, Gillman MW. A nearly continuous measure of birth weight for gestational age using a United States national reference. BMC Pediatr. 2003;3:6. Epub 2003 Jul 8

Level III

Alberry M, Soothill P. Management of fetal growth restriction. Arch Dis Child Fetal Neonatal Ed. 2007;92:F62.

Alexander GR, Kimes JH, Kaufman RB, et al. A United States national reference for fetal growth. Obstet Gynecol. 1996;87:163.

American College of Obstetricians and Gynecologists. Intrauterine growth restriction. ACOG Practice Bulletin 12. Washington, DC: ACOG, 2000.

American College of Obstetricians and Gynecologists. Ultrasonography in pregnancy. ACOG Practice Bulletin 58. Obstet Gynecol. 2004;104:1449.

Baschat AA. Fetal responses to placental insufficiency: an update. BJOG. 2004;111:1031.

Bloomfield FH, Oliver MH, Harding JE. The late effects of fetal growth patterns. Arch Dis Child Fetal Neonatal Ed. 2006;91:F299. Review.

Chien PF, Arnott N, Gordon A, et al. How useful is uterine artery Doppler flow velocimetry in the prediction of pre-eclampsia, intrauterine growth retardation and perinatal death? An overview. BJOG. 2000;107:196.

Goldenberg RL, Cutter GR, Hoffman HJ, et al. Intrauterine growth retardation: standards for diagnosis. Am J Obstet Gynecol. 1989;161:271.

James D. Diagnosis and management of fetal growth retardation. Arch Dis Child. 1990;65:390.

Resnik R. Intrauterine growth restriction. Obstet Gynecol. 2002;99:490.

Seeds JW. Impaired fetal growth: definition and clinical diagnosis. Obstet Gynecol. 1984;64:303.

Seeds JW. Impaired fetal growth: ultrasonic evaluation and clinical management. Obstet Gynecol. 1984;64:577.

Strauss RS, Dietz WH. Effects of intrauterine growth retardation in premature infants on early childhood growth. J Pediatr. 1997;130:95.

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