Incidence :

• Develop countries : 2-8%
• Term IUGR : 5%
• Post – term : 15%

Types of Intrauterine growth restriction IUGR : 

Features those are small and healthy : The birth weight is less than 10th percentile for their gestational age. They have normal ponderal index, normal subcutaneous aft and usually have uneventful neonatal courses.

True Intrauterine growth restriction IUGR : Fetuses where growth is restricted by pathological process. Depending upon the relative size of their head, abdomen and femur they are subdivided into two groupes –

• Symmetrical or type 1 (20%).
• Asymmetrical or type (80%).

Note : 

• Neonatal fetal growth is characterized by cellular hyperplasia followed by hyperplasia and hypertrophy and lastly by hypertrophy alone.
• 2/3rd of the fetal weight gain occurs beyond 24th weeks of pregnancy.

Causes of Intrauterine growth restriction  (IUGR) : 

A) Unknown (40%)/ idiopathic.

B) Maternal causes of IUGR : 

1. Constitutional :  

• Small women.
• Maternal genetic and racial background.

  2. Maternal nutrition before pregnancy : Under – nutrition and                            malnutrition before pregnancy.

  3. Maternal distress : 

• Anaemia
• Hypertension
• Heart disease
• Chronic renal diseases
• Thrombophilias
• Collagen vascular diseases.

  4.Toxins : Alcohol, smoking, cocaine, heroin, drug, etc.

5. Maternal obstetric disease :  Pre-eclampsia.

C.Fetal causes of IUGR : 

1. Structural abnormality : Cardiovascular, renal or others.
2. Chromosomal abnormality (8-10%) : Trisomosis (11,18, 21) and Turner’s syndrome , triploidy and aneuploidy.
3. TORCH infection
4. Malaria
5. Multiple pregnancy.

D) Placental causes of IUGR : 

1. Placenta praevia
2. Abruptio placenta.
3. Cricumvallate placenta
4. Infarction.
5. Mosaicism.

Clinical features of Intrauterine Growth Restriction IUGR : 

1. Palpation of the uterus : For fundal height, liquor volume and fetal mass (but less sensitives as because their variation detects clinically is very difficult).
2. Symphysis – fundal height (in cm) : Closely correlates with gestational age after 24 weeks. A lag of 4 cm or more suggest growth retardation. It is a fairly sensitive parameter (30-80%).
3. Maternal weight gain : Stationary or at times falling during the 2nd half of the pergnancy.
4. Abdominal girth : Stationary or falling values.
5. Features of an IUGR baby : All these features give the baby an old man look.

• General appearance : The baby is alert, active and having normal cry.
• Weight : About 600 g below the minimum in percentile standard.
• Length : Unaffected
• Head circumference : Relatively larger than the body in asymmetric variety.
• Skin : Dry and wrinkled due to less subcutaneous fat.
• Abdomen : Scaphoid shaped.
• Vermix caseosa : Thin and muconium stained.
• Umbilical cord : Thin
• Eyes : Eyes are open.
• Reflexes : Normal (including More reflex).
• Planter creases : well defined.
• Pinna of ear has cartilaginous ridges.

Investigation of Intrauterine Growth Restriction (IUGR) : 

1. Ultrasonography : Ultrasonography should be done at 3-4 weeks interval to asses BPD, HC/AC, fetal weight and amniotic fluid index.

• Head circumference and abdominal circumference ratio elevated
• Femur length and head circumference ratio elevated.
• Reduced amniotic fluid volume.

Treatment of Intrauterine growth Restriction (IUGR) : 

A) General treatment : 

1. Adequate bed rest especially in left lateral position.
2. DIet : Correction of malnutrition by balanced diet with extra 300 Kcal.
3. High flow O2 inhalation.
4. Avoidance smoking and alcohol.
5. Low dose aspirin (50 mg/day) may be helpful in selected cases with H/O thrombotic disease, hypertension, preeclampsia or recurrent IUGR.

B) Obstetric treatment : Termination of pregnancy : The factors that complex for termination are : 

1. Presence of fetal abnormality and genetic disorders.
2. Duration of pregnancy.
3. Degree of growth  restriction.
4. Association of complicating factors.
5. Degree of fetal compromise.
6. Previous obstetric history.
7. Facilitates available at the place of delivery.

For more curiosity 

Indication of C/S in IUGR : In case of preterm labour with unfavourable cervix.

Care during NVD in IUGR : 

• The delivery should be in an equipped institution where intensive intra-snatal monitoring (clinical and electronic) is possible and having facilities for  intensive neonatal care unit. Otherwise in utero transfer of the baby to an equipped center should be done.
• The Precautions during labour are those required for preterm delivery.

Immediate care of the newborn in IUGR : 

• A neonatologist should be available at the time of delivery.
• The same precautions as outlined in the premature delivery are to be taken
• The baby should be placed preferably in the intensive neonatal care unit.

Complication of Intrauterine Growth Restriction (IUGR) : 

Fetal complications : 

A) Antenatal : 

• Chronic fetal distress.
• Fetal death.
• Congenital infection.
• Congenital abnormalities and chromosomal defect.

B) Intranatal : 

• Hypoxia
• Acidosis

C) Post natal / after birth :

a) Immediate : 

1. Asphyxia (intrauterine and neonatal)
2. Acute RDS.
3. Hypoglycaemia (due to chronic hypoxia).
4. Meconium aspiration syndrome.
5. Micro – coagulation and DIC.
6. Hypothermia
7. Pulmonary haemorrhage
8. Polycythaemia.
9. Hyperviscosity syndrome
10. Necrotizing enterocolitis.
11. Inter – ventricular haemorrhage.

B) Late : 

1. Growth retardation after birth.
2. Retarded intellectual and neuroligical development.
3. In adulthood : Risk of type 2 DM, CVS disease and hyperlipidaemia.

Maternal complications :

IUGR may causes any harm to the mother, but the underlying disease process : such as pre – eclampsia, heart disease, malnutrition may be life threating.