IUGR, JNMCH, AMU, ALIGARH

1. PRESENTED BY : DR.NEHA JAIN
Jnmch, amu aligarh

2. Mrs.X,
Wife of Mr. Y,
Age 23yrs
Resident of N district.
Unbooked case
Presented with complaint of :
Cessation of menses- 81/2 mths
Ghabrahat- 3 days

3. History of present illness:
Patient was apparently all right 81/2 mths back
when she developed cessation of menses.
1st TRIMESTER: No H/O
excessive nausea & vomitting
bleeding p/v
fever with or without rashes
drug intake
radiation exposure

4. 2nd TRIMESTER: H/O poor weight gain
No H/O headache
epigastric pain
blurring of vision
bleeding or leaking p/v
Pain abdomen
Quickening @ around 5th mth
3rd trimester: H/O Ghabrahat on & off
No H/O headache
epigastric pain
blurring of vision
bleeding or leaking p/v

5. Menstrual History:
LMP-01/12/2013
By Dates-36 wks 3 days(dates sure)
By 30 wks scan-32 wks 4 days
No H/O prolonged menstrual cycles/
normal flow
Obstetric history:
G2P1+0L0  0 / IUD delivery @
8mths GA / Govt.hospital / 1yr. back / cause N/K

6. Past history: No H/O Hypertension
Renal disease
Diabetes mellitus
Heart disease
Asthma
Thrombophilias
Personal history: Sleep-N,Bladder/Bowel-N
No H/O smoking
alcoholism
drug abuse

7. Dietary history:
2-3 chapatis/day
1 small bowl of dal
1 small bowl of vegetables
Rice occasionally
1 spoon ghee, 2 spoons oil
Calorie intake-1200kcal./day(Requirement-1900kcal.)
Iron tablets not regular
No calcium tablets

8. Socio economic status:
Poor
Kuppuswamy class-Upper lower(IV)
Family history: No H/O HTN/DM/Asthma/TB
No H/O genetic disorder in family

9. General examination:
Thin built
Poor nutritional status
Height -152cm.
Weight - 55kg.
BMI- 22.9 Kg/m2
Pallor + (clinically 8g%)
Cyanosis & Icterus -nt
Cervical lymphadenopathy-nt
Pedal edema +nt

10. Vitals:
Pulse - 94/min, regular, good volume,
no radiofemoral delay
Bld. Pressure- 110/70mmHg.
Resp.rate- 20/min
Temp.- Afebrile
Systemic examination:
CNS
CVS
RESP.
WNL

11. Abdominal examination:
Distended
Skin loose
Uterus 30-32wks
SFH-30cms
cephalic
Liquor clinically normal
FHS+nt, 132/min. regular
Uterus relaxed X 10 min.

12. Hb% - 8.5
Bld grp.- A+ve
TLC - 7800/cu mm.
DLC - P70L28M02
Platelets- 1.8 lacs/cu mm.
Bld Sugar ®- 124 mg/dl.
S.Urea - 30mg%
S.Creatinine- 0.42 mg%
HIV, HBsAg, VDRL- NR

13. •
•
•
•
•
Wrong Dates
Small for Gestation Age(SGA) fetus
Pathological Fetal Growth Restriction(PFGR)
Intra Uterine Fetal demise
Oligohydraminos

14. next
investigation
to
confirm…???

16. Doppler effect:
• Change in the apparent frequency due to relative
motion between the source & the observer.
(Doppler probe & RBCs)
• When the sound wave strikes a moving target, the
frequency of sound waves reflected back is
proportionate to the velocity & direction of
moving object.
• Used to determine the volume & rate of blood
flow through maternal vessels

17. Types:
1) CONTINUOUS WAVE DOPPLER:
Two crystals are used, one transmits & other receives
wave
Used in M-mode echocardiography
1) PULSE WAVE DOPPLER:
Only one crystal that
Transmits-wait-Receives-wait-Transmits
Allows precise targeting & visualization of the vessel
of interest
Have software that displays blood flowTowards transducer as RED
Away from transducer as BLUE

18. • Angle of Insonation: Between doppler beam &
direction of flow
• Higher the angle lesser the frequency & more
the error.

19. Frequency change relative
to angle of insonation

20. • To minimize error we use RATIOS, to cancel off
the cosϴ
Arterial Doppler indices
 S/D Ratio: Peak systolic flow(S)
End diastolic flow(D)

21.  PULSATILITY INDEX : S-D
Mean
 RESISTANCE INDEX : S-D
S
Venous Doppler indices:

22.  PRELOAD INDEX :
Peak velocity during atrial contraction
Peak systolic velocity
 PEAK VELOCITY INDEX :
Peak Systolic – Peak velocity atrial contraction
Peak Diastolic velocity
 PERCENTAGE REVERSE FLOW :
Systolic time averaged velocity
X 100
Diastolic time averaged velocity
 PULSATILITY INDEX :

23. MATERNAL COMPARTMENT
FETAL COMPARTMENT
•Uterine Artery
•Umblical Artery
•Middle Cerebral Artery
•Venous Doppler

24. Uterine artery Doppler:
• High diastolic flow velocities

25. • Its main use is in screening.
• Early diastolic notch in the uterine artery
@ 12-14 wks. suggest delayed trophoblastic
invasion (JAMES)
• Persistence of notch beyond 24 wks confirms &
indicates an increase risk of Pre-eclampsia,
Placental abruption & Early onset IUGR. (JAMES)
• Increase impedence of flow in Uterine artery
@ 16-20 wks was predictive of superimposed
pre-eclampsia developing inwomen with chronic
hypertension. (WILLIAMS)

27. Umbilical ARTERY DOPPLER
• The amount of flow during diastole increases as gestation advances
• Thus the S/D ratio dec. from 4 @ 20 wks to 2 @ 40 wks. (WILLIAMS)
• Umbilical A. S/D ratio is generally < 3 after 30 wks. (WILLIAMS)

28. • Umbilical A. Doppler indices should be measured
only after 23 wks (STUDD)
• It is useful adjunct in the management of
pregnancies complicated by fetal-growth restriction.
(ACOG-2008)
• It is not recommended for screening of low-risk
pregnancies or for complications other than growth
restriction. (WILLIAMS)
• Umbilical artery Doppler becomes abnormal when
at least 30% of the fetal villous structure is
abnormal. (JAMES)

29. •In extreme cases of growth restriction, end-diastolic
flow may become absent or even reversed (AREDF).
•AREDF occurs when 60-70% of the fetal villous
structure is abnormal.
•About ½ of the cases of AREDF are associated with
aneuploidy or a major anomaly (WILLIAMS)
•Fetuses of preeclamptic women who had AREDF
were more likely to have hypoglycemia &
polycythemia. (WILLIAMS)

30. ABNORMAL Umbilical ARTERY
WAVEFORM
Resistance index & S/D ratio is increasing

31. ABNORMAL Umbilical ARTERY
WAVEFORM
Perinatal mortality rate in AEDF- 9-41% (IAN DONALD’S)

32. ABNORMAL Umbilical ARTERY
WAVEFORM
Reversal of the End Diastolic Flow
Perinatal mortality rate of REDF- 33-73% (IAN DONALD’S)

33. • Abnormal Umbilical artery flow pattern indicate an increased
risk of hypoxemia & acidemia proportionate to severity of
Doppler abnormality. (JAMES)
• Umbilical artery Doppler can also be used to distinguish b/w
the high risk small fetus that is truly growth restricted that
needs inc. monitoring & the low risk small fetus. (IAN DONALD’S)
• When Umbilical artery Doppler are incorporated into
management algorithm of growth restricted fetus, perinatal
death is reduced as much as 29%. (STUDD)
• In summary UA Doppler in suspected IUGR pregnancies
improves perinatal outcome & should be used to monitor these
fetuses

34. Ductus arteriosus doppler
• Primarily used to monitor fetuses exposed to
indomethacin and other NSAIDs.
• Indomethacin was used for tocolysis
• They causes Premature closure of Ductus
Arteriosus  Increased pulmonary flow 
Reactive hypertrophy of pulmonary arterioles 
Pulmonary Hypertension.
WILLIAMS 23rd EDITION

35. MIDDLE CEREBRAL ARTERY(MCA)
DOPPLER
• It was used for assessment ofFetal Anemia
Growth restriction
 FETAL ANEMIA: (In Rh isoimmunisation)
With increasing anemia  cardiac output increases
& blood viscosity decreases  increase flow to
brain  Elevated peak systolic velocity
WILLIAMS 23rd EDITION

36. Normal MCA WAVEFORM

37. MCA DOPPLER IN FETAL ANEMIA
INCREASED PEAK SYSTOLIC VELOCITY

38. Why only Middle Cerebral Artery is
used in assessing fetal anemia…???
• Other vessels have high insonating angles
• MCA is an exception because anatomically,
the path of this artery is such that flow velocity
approaches the transducer "head-on," and the
fontanel allows easy insonation
(WILLIAMS 23RD EDITION)

39.  GROWTH RESTRICTION:
It is involved in severely growth restricted fetus
after involvement of Umbilical artery.
It is the progression of the Doppler finding & is
due to the adaptive compensatory mechanism
in the fetus against increasing hypoxia (Brain
sparing effect)

40. Umbilical artery involved
Increasing hypoxia
Inc. blood flow to Vital
Organs(Brain, Heart&
Adrenals)
BRAIN SPARING EFFECT
Or
CEPHALISATION
Dec. blood flow to
Abdominal Organs(Liver &
Kidneys)
MCA DOPPLER- Inc.
Diastolic Flow
OLIGOHYDRAMINOS
Dec. RI/PI/SD ratio & abn MCAPSV

41. MCA WAVEFORM IN IUGR
INCREASED FLOW DURING DIASTOLE

42. CEREBRO-PLACENTAL RATIO(CPR):
MCA Pulsatility Index
Umbilical A. Pulsatility Index
It is more sensitive index for detecting poor
perinatal outcome than UA or MCA Doppler
alone, but due to non standardized technique of
calculating CPR limit its clinical utility. (STUDD)

43. • Abnormal MCA reflects inc risk of adverse perinatal
outcome(PTL, Intrapartum acidemia & inc NICU
admission)
• Not superior to Umbilical artery Doppler
• High negative predictive value for adverse outcome
• Normal UA & MCA Doppler indices & normal AFI
in growth restricted fetus <32 wks have negative
predictive value of 97% for adverse outcome

44. Umbilical artery involved
Increasing
MCA-PSV IS
THE BETTER
TOOL TO
hypoxia
FOLLOW THE
PROGRESSION
OF THE
DISEASE
Dec. blood flow to
(STUDD)
Abdominal Organs(Liver &
Kidneys)
Inc. blood flow to Vital
Organs(Brain, Heart&
Adrenals)
BRAIN SPARING EFFECT
Or
INCREASING HYPOXIA
CEPHALISATION
DECOMPENSATION
MCA DOPPLER- Inc.
OLIGOHYDRAMINOS
Diastolic Flow
NORMALSATION OF MCA
DOPPLER INDICES EXCEPT
Dec. RI/PI/SD ratio &
FOR
Abn MCA-PSV
MCA-PSV

45. SUMMARY OF MCA:
Despite the association of abn. MCA & adverse
perinatal outcome, there are no specific
interventions to improve outcome based on
abn. findings.
However abn. values should prompt more
frequent fetal survillence

46. Venous Doppler studies
• Reflects fetal cardiac function
• Most commonly used Venous Doppler indices:
Ductus Venosus
Inferior vena cava
Hepatic vein
Umbilical vein(Intra abdominal portion)

47. VENOUS DOPPLER
All venous Doppler have this type of waveform except for Umbilical vein
waveform

48. Ductus venosus doppler
PERINATAL MORTALITY IN ABSENT OR REVERSE FLOW OF DV IS
63-100% (IAN DONALD’S)

49. HYPOXIA
INC BLOOD SHUNTING THROUGH
DV B/W UMBILICAL VEIN & IVC PSV-ATRIAL CONTRACTION
VELOCITY
Avg. Vel. Drng cardiac cycle
INC. PULSATILITY
INDEX FOR VEINS (PIV)
REVERSED a WAVE
IN
DV PULSATION
PULSATIONS IN THE
UMBILICAL VEIN
REVERSAL OF FLOW IN
IVC DURING ATRIAL
CONTRACTION

50. ABNORMAL WAVEFORM IN
UMBILICAL VEIN

51. Important points on venous
Doppler
• Especially useful in early onset IUGR
Reason: In Term /near term fetuses
there is shorter interval & delivery is often
indicated
With advancing GA cardiac
activity becomes more efficient  slow Steady
decline in Doppler indices
• When DV & Umbilical vein Doppler- Sensitivity
inc to 70-80%.

52. Current areas in research &
investigation
•
POST TERM PREGNANCY:
Pregnancy >41 wks
Abn. CPR & MCA indicate adverse outcome
•
DETERMINATION OF PLACENTATION: To identify Placenta Accreta, Increta,Percreta
Specific sonographic findings:
Absence of hypo echoic zone retro placental zone
Presence of numerous placental lakes
interruption of bladder-myometrium interface
Sensitivity is low
Negative predictive value-95%
3D power Doppler: Sensitivity-97%; Specificity-92%
•
PREDICTION OF INTRAPARTUM ACIDEMIA:
•
OXYGEN THERAPY FOR IUGR FETUSES:
Continuous oxygen therapy for AEDF fetuses
30% reduction in perinatal mortality

53. PERINATAL MORTALITY RATES
DOPPLER PARAMETER
PERINATAL MORTALITY
INC. UMBLICAL A. RESISTANCE
5-6%
ABSENT UMBLICAL A. EDF
11-13%
REVERSED UMBLICAL A. EDF
20-24%
DECREASED MCA
21%
ABN. DV a WAVE
30-38%
INTRA ABD. UMBLICAL VEIN
PULSATIONS
35%

56. What
is
your diagnosis
???...
G2P1+0L0 with 36wks 3 days pregnancy
with moderate anemia with IUGR

59. hyperplasia
• First 16 wks
• Rapid mitosis
• Inc. in DNA content
Hyperplasia &
hypertrophy
• 17-32 wks
• Dec. mitosis
• Inc. in cell size
hypertrophy
• After 32 wks
• Inc. in cell size, fat
deposition, muscle
mass & connective
tissue
15 wks - 5g/day
24 wks - 1020g/day
34 wks - 3035g/day
WILLIAMS OBSTETRICS -23rd EDITION

60. GENETIC POTENTIAL
• Derived from both parents
• Mediated through factors like insulin like growth factor
 SUBSTRATE SUPPLY
• Derived from placenta
• Depend upon Uterine & Placental vascularity

61. glucose
Fetal
growth
oxygen
Amino
acids

63. BIRTH WEIGHT
thPERCENTILE OF THAT
<10
GESTATION
(OR)
WEIGHT <2SD of THE MEAN

64. FETAL GROWTH RESTRICTION
(Or)
SMALL FOR GESTATION
AGE(SGA)(3-10%)
CONSTITUTIONAL
PATHOLOGICAL
(IUGR)

65. • TYPE 1/ SYMMETRICAL /INTRINSIC: (20-30%):
• Growth inhibition early in the pregnancy (4-20 wks)
•
•
•
•
•
Affects Hyperplastic stage
Causes are: Intrauterine infections (TORCH)
Congenital malformations
HC, AC, FL & Weight below 10th percentile for GA
Hence Ponderal Index Wt.(gm)is normal
FL(cm)3
• Causative factor is usually uncorrectable.

66. TYPE 2/ aSYMMETRICAL /exTRINSIC:(70-80%):
• Occurs later, usually after 28 wks of GA
• Affects hypertrophic stage
• Due to restriction of nutrient supply in utero
• Associated with maternal d/s.- Chronic Htn., Renal d/s.,
Vasculopathy etc.
• Brain Sparing Effect
• HC & FL- normal, AC- decreased
• Ponderal index- low

67. TYPE 3/ intermediate iugr(5-10%)
• Combination of Type-1 & type-2
• Affects both Hyperplasia & Hypertrophy
• Associated with Chronic Htn., Lupus nephritis,
vascular d/s. in early 2nd trimester

69. PLACENTAL CAUSES
•
•
•
•
•
•
•
Placenta Previa
Abruptio Placentae
Placental thrombosis or infarction
Deciduitis, Placentitis, Vasculitis, Edema
Chorioamnionitis
Placental Cyst
Chorioangioma

70. FETAL CAUSES
•
•
•
•
•
Infections
Malformations
Heart Disease
Chromosomal abnormalities
Osteogenesis Imperfecta

71. Maternal causes
•
•
•
•
•
•
•
•
Race, Weight, Height
Cardiovascular disease
Renal disease, Acidosis
Anemia
Fever
Drug intake(DES, Anticancer, Narcotics)
Smoking
Alcohol

72. Uterine Causes
• Decreased uteroplacental blood flow
• Atheromatosis or Arteriosclerosis of the decidual
spiral arteries
• Chronic Hypertension
• Preeclamsia
• Diabetes Mellitus
• Connective tissue disorders
• Fibromyomas
• Morphologic abnormalities

73. • Perinatal morbidity & mortality of IUGR infants
is 3-20 times greater than normal infants(IanDonalds)
• Risk is increased 3times at 26 weeks compared
with only a 1.13-fold increased risk at 40
weeks.(Williams 23rd edition)

74. Antenatal Period:
• Oligohydraminos
• Fetal Distress
• IUD
During labour:
•
•
•
•
Still birth
Meconium aspiration
Fetal distress
Acidosis

75. neonatal period:
• Hypoxic Ischemic Encephalopathy
•
•
•
•
•
Persistent Fetal circulation
Difficulty in temperature regulation
Hypoglycemia
Polycythemia
Necrotising Enterocolitis

76. Childhood:
• Infectious Diseases
•
•
•
•
Congenital Anomalies
Cerebral Palsy(4-6 times higher)[Ian Donalds]
Subtle impairment in cognitive improvement
Educational underachievement

77. Long term:
Inc. risk of 
•
•
•
•
•
Coronary Heart Disease
Hypertension
Type II Diabetes Mellitus
Dyslipidaemia
Stroke

78. History:
• Correct gestational age
•
•
•
•
•
•
•
History of Previous IUGR baby
History of disorders affecting placental function
Obstetric history
Dietary history
Drug / Radiation exposure / Addiction
Family history
Socioeconomic status

79. Examination:
 General examination
 Systemic examination
 Obstetrical examination-SFH /AG
• After 20 wks SFH corresponds to the no. of wks. of gestation.
(JAMES)
• Between 18-30wks. SFH coincides within 2wks of GA & a lag
of 2-3cms. Denotes growth restriction (WILLIAMS)
• SFH increases by 1cm/wk b/w 14-32wks. A lag of > 4 wks
denotes moderate IUGR & > 6wks denotes severe IUGR. (IAN
DONALD’S)
• AG increases by 1 inch/wk. after 30 wks. It is 30inch @ 30 wks

80. Investigations:
 Routine ANC investigations
 ULTRASOUND: Most useful inv.
• Gestation age determination- prior to 24 wks, but most
accurate @10-12 wks
CRL is the most accurate parameter(WILLIAMS)
There is an error of around:
7days in 1sttrimester
10-11 days in 2ndtrimester
21 days in 3rdtrimester (JAMES)
• Determination of EFW: AC & EFW inc the sensitivity
• Determination of multiple gestation
• Determination of Fetal wellbeing

81. • Determination of Congenital anomalies:
@ 16-20 wks of gestation (WILLIAMS)
• Determination of placenta:
• Assessment of fetal growth:
Repeat @ 32-34 wks
BPD(Bi Parietal Diameter)- Most accurate for
dating in 2ndtrimester (14-26wks) [WILLIAMS]

82. Proximally-outer table,
Distally-inner table
MEASURED@ THE LEVEL OF THALAMUS & CAVUM SEPTUM PELLUCIDUM
WILLIAMS 23rd EDITION

83. HC(Head Circumference):
More accurate than BPD in
Dolicocephalic or Brachycephalic head
CEPHALIC INDEX:
Ratio of BPD to Occipitofrontal diameter.

84. FL(Femur Length):
Measured @ the level perpendicular to shaft excluding the
epiphysis
Correlates well with the BPD & Gestational age
AC(Abdominal Circumference):
Single best parameter for detection of IUGR because it is
related to the liver size which reflects fetal glycogen
storage (JAMES)
Its sensitivity is further inc. by serial measurements atleast
14 days apart (JAMES)
We should not not label as growth restricted fetus unless
AC is far below normal or unless other parameters
correlate. (JAMES)

85. ABDOMINAL CIRCUMFERENCE
DONALD SCHOOL OF ULTRASOUND

86. TCD(Trans Cerebellar Diameter): Correlates well
with the gestation age
Relatively spared in mild to moderate
Uteroplacental dysfunction.
Upto 25 wks TCD in cms. = GA (IAN DONALD’S)

87. Age independent ratios
HC/AC:
Decreases linearly from 16-40wks. normally.
Ratio>2SD is suggestive of IUGR (IAN DONALD’S)
FL/AC:
Normal value = 22 + 2% in second half of preg.
Ratio above23.5% is abnormal (IAN DONALD’S)

88. • Determination of Amniotic Fluid Volume:
Type II IUGR causes Oligohydraminos
Amniotic Fluid Index(AFI) = 5-18 cms.
Maximum Liquor Pocket = 2-8 cms.

89. Other investigations
 Amniocentesis
 Karyotyping
 Colour doppler
 TORCH test
 Antiphospholipid antibody
 Thrombophillia screen
 Thyroid function test
 Detailed level II ultrasound
 Biophysical Profile(BPP)
 Cardiotocography

90. Presumptive diagnosis of iugr
• SFH not increasing at a normal rate
• Fetuses with small AC
• Flattening of growth curve on two consecutive occasion
14 days apart
• Beyond 24 wks., an elevated umbilical artery Doppler index
• After 34 wks umbilical artery Doppler index may be normal
& a dec. CPR or MCA Doppler index may be the only
supporting evidence of placental-based IUGR

91. Based on the above findings, the fetus
may have one of the four diagnosis:
•
•
•
•
Aneuploidy
Viral infection
Placental dysfunction (Most Common)
Non Aneuploidy fetal Syndrome

92. Diagnostic work-up
• It is imp. to decide the cause of IUGR before
delivering the fetus

93. Clinical suspicion of IUGR
AC/EFW<10 th
PERCENTILE
Anatomical survey &
AFI
Normal /
oligohydraminos
Umbilical Artery Doppler
/ MCA Doppler
Norma
l
Anomaly/
polyhydrami
nos
Dec./AREDF/
brain sparing
effect
•Aneuploidy
•Syndromes
•Viral infections
Placental
insufficiency
Abnorm
al
Cerebro-Placental ratio
Norma
l
Repeat USG after 14 days
constitutional

94. Maternal & fetal therapy
• Reduce/ Eliminate the potential external
contributors(Stress/ smoking)
• Encourage maternal rest daily in LLL
• Low dose aspirin-75mg/day
Used for mild placental dysfunction
Found useful when started in 1st trimester
• Fetal therapy:
Maternal Hyper oxygenation
Intra vascular volume expansion
JAMES 4 edition
Hyperailmentation
th

95. • Antenatal administration of corticosteroids in < 34wk
to hasten fetal lung maturity.
• Delivery of the fetus in an institution having
Neonatal care unit that can carry complex
management of the neonate with IUGR
JAMES 4th edition

96. Timing & mode of delivery
• Frequent surveillance of growth-restricted fetuses is
essential to optimize timing of delivery & maximizing GA
while minimizing the risk of neonatal morbidity &
mortality
• More than 60% of the fetus with abnormal heart rate are
already hypoxemic or acidemic. (STUDD)
• Doppler findings precede Biophysical profile & Non
Stress Test by several wks. (STUDD)
• Umbilical A.  MCA  venous Doppler  BPP  CTG
• Integrated fetal testing is used to monitor timing.

97. • Management algorithm depends heavily on
 Gestation age(upto 29 wks)
 Umbilical A. Doppler
Difficult
extrauterine
environment
Hostile
intrauterine
environment

98. IUGR> 24 WKS
Normal /
mildly
elevated
UMBILICAL A. DOPPLER
•NST twice weekly
•BPP weekly
•AFI Weekly
•Umbilical A. Doppler wkly
•Fetal growth 3 wkly
NOR
MAL
Deliver @ 37-39wks
ABNOR
MAL
AREDF
•Hospitalise the pt.
•Continuous /frequent fetal
monitoring
•Corticosteroids
•MCA Doppler wkly
•DV Doppler every 3-4days
•BPP daily
•Fetal growth every 3 wks
NOR
MAL
Deliver @34-36 wks
RCOG 2013- 37wks
RCOG 2013- 32wks
STUDD

99. MODE OF DELIVERY
UMBILICAL A. DOPPLER
RAISED
AREDF
CAESAREAN
VAGINAL
CAESAREAN

100. THANK
YOU