Intrauterine Growth Retardation

Aka: Intrauterine Growth Retardation, Intrauterine Growth Restriction, Fetal Growth Retardation, Fetal Growth Restriction, Small for Gestational Age, IUGR

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II. Definitions

  1. Fetal Growth Restriction or Intrauterine Growth Retardation (IUGR)
    1. Estimated fetal weight (ACOG) or abdominal circumference (MFM) < 10% for Gestational age
  2. Severe Fetal Growth Restriction or IUGR
    1. Estimated fetal weight <3%
  3. Small for Gestational Age (SGA)
    1. Newborn with birth weight <10% for Gestational age

III. Epidemiology

  1. Affects up to 10% of pregnancies

IV. Causes: Fetal

  1. Genetic Causes
    1. Trisomy 13, Trisomy 18, Trisomy 21
    2. Cornelia de Lange Syndrome
    3. Fanconi Anemia
  2. Major Congenital Abnormalities
    1. Anencephaly
    2. Congenital Heart Disease
    3. Diaphragmatic Hernia
    4. Omphalocele
    5. Transesophageal Fistula

V. Causes: Maternal Chronic Disease

  1. Cardiovascular Disease
    1. Coronary Artery Disease
    2. Congestive Heart Failure
    3. Congenital Heart Disease
    4. Hypertensive Disorders of Pregnancy (e.g. Preeclampsia)
  2. Lung Disease
    1. Uncontrolled Severe Asthma
      1. Bracken (2003) Obstet Gynecol 102:739-52 [PubMed]
    2. Chronic Obstructive Lung Disease (COPD)
    3. Cystic Fibrosis
  3. Miscellaneous Conditions
    1. Systemic Lupus Erythematosus (or other Collagen vascular disease)
    2. Inflammatory Bowel Disease (Crohn Disease, Ulcerative Colitis)
    3. Severe Anemia including Sickle Cell Disease
    4. Chronic Diabetes Mellitus
      1. Second most common cause of IUGR (Tobacco Abuse is first)
    5. Renal Insufficiency

VI. Causes: Pregnancy Related Conditions

  1. Assisted Reproduction
  2. Socioeconomic factors (e.g. decreased maternal nutrition)
  3. Uterine Fibroids (or other uterine abnormalities limiting Intrauterine Growth)
  4. Infectious Disease
    1. TORCH Virus
      1. Toxoplasmosis
      2. Syphilis
      3. Rubella
      4. Cytomegalovirus (CMV)
      5. Herpes Simplex Virus (HSV)
    2. Listeria
    3. Tuberculosis
    4. HIV Infection
    5. Malaria
    6. Varicella
  5. Multiple Gestation
  6. Prior history of Small for Gestational Age infant
  7. Short interval between pregnancies
  8. Illicit Drugs
    1. Maternal Tobacco Abuse
      1. Most common preventable cause of IUGR
      2. Birth weight reduced 200 grams if mother smokes
    2. Maternal Alcohol Use (e.g. Fetal Alcohol Syndrome)
      1. No amount of Alcohol is safe!
    3. Cocaine
    4. Tobacco
    5. Opioids (Heroin, Methadone)
  9. Medications
    1. Antithrombotic Medications
    2. Cyclophosphamide
    3. Valproic Acid
    4. Phenytoin
  10. Placental Abnormalities
    1. Placental Abruption
    2. Placental Infarcts
    3. Abnormal placenta implantation
  11. Umbilical Cord Abnormalities
    1. Marginal Cord Insertion
    2. Two vessel cord (Single Umbilical Artery)

VII. Types

  1. Fetal asymmetry does not predict complications
    1. IUGR is now classified by onset before or after 32 weeks
  2. Early onset Fetal Growth Restriction (<32 weeks gestation) accounts for 20-30% of cases
    1. Previously described as Symmetric Intrauterine Growth Retardation
    2. More severe and progressive
    3. Associated with decreased umbilical artery flow in 70%
    4. Associated with perinatal death in 7%
    5. Associated with Preeclampsia inm 35% of cases
    6. Chromosome or genetic abnormalities in 20% of cases
  3. Late onset Fetal Growth Retardation (>32 weeks gestation)
    1. Previously described as Asymmetric Intrauterine Growth Retardation (70-80% of cases)
    2. Less severe than early onset
    3. Abnormal umbilical artery in <10%
    4. Rare perinatal death
    5. Associated with Preeclampsia in 12% of cases

VIII. Diagnosis: Level 2 Obstetric Ultrasound

  1. Indications: Exam Findings Suggestive of IUGR
    1. Poor Maternal Weight gain
      1. Most sensitive indicator for IUGR
    2. Fundal Height less than expected for Gestational age (fundal height <3 cm below Gestational age)
      1. Follow serial fundal height measurements at every visit after 24 weeks
      2. Fundal heights may be inaccurate due to body habitus, Multiple Gestation, Uterine Fibroids
  2. Indications: History Findings increasing IUGR Risk (see causes above)
    1. Tobacco Abuse (most significant individual risk)
    2. Poor Nutrition
    3. Illicit Drug Use
    4. Alcohol Abuse
    5. Minimal to no Prenatal Care
    6. Traumatic stress
    7. Prior pregnancy with IUGR or infant SGA
    8. Maternal chronic disease
  3. IUGR Test Sensitivity
    1. Detection rate in-utero: 70%
  4. Level 2 Obstetric Ultrasound (Detailed Anatomy Survey) Interpretation
    1. Estimated Fetal Weight and Abdominal Circumference <10% consistent with IUGR
    2. Head Circumference to Abdominal Circumference ratio
      1. Most useful in assessing Asymmetric IUGR
    3. Consider repeat Level 2 Ultrasound in 4 weeks if initial Ultrasound does not meet IUGR criteria

IX. Evaluation: Confirmed IUGR

  1. Maternal-Fetal Medicine Consultation recommended in all cases of IUGR
  2. Cardiocartography
  3. Umbilical Artery Doppler End-Diastolic Velocity (EDV)
    1. Normal EDV
      1. Estimatated Fetal Weight <3% for Gestational age (Severe Fetal Growth Restriction)
        1. MFM-directed monitoring
        2. Target delivery at 37 weeks
      2. Estimatated Fetal Weight >3% for Gestational age
        1. MFM-directed monitoring
        2. Target delivery at 38-39 weeks
    2. Decreased EDV
      1. MFM-directed monitoring
      2. Target delivery at 37 weeks
    3. Absent EDV
      1. MFM-directed disposition (consider admission)
      2. Target delivery at 33-34 weeks
    4. Reversed EDV
      1. Emergent Hospital Admission
      2. Target delivery at 30-32 weeks
  4. Chromosome MIcroarray analysis
    1. Obtained by Cell-Free DNA (non-invasive) or Chorionic Villus Sampling or Amniocentesis (invasive)
    2. False Positive Rate: 5%
    3. Indications
      1. Unexplained Early Onset Growth Restriction <32 weeks gestation
      2. Ultrasound structural abnormality
      3. Polyhydramnios
  5. Fetal Assessment monitoring of growth restriction ongoing after 24 weeks (at least every 3-4 weeks)
    1. Biophysical Profile or Non-Stress Test twice weekly
    2. Serial Obstetric Ultrasounds for growth
    3. Umbilical Artery Doppler End-Diastolic Velocity every 1-2 weeks (every 4 weeks if consistently normal)

X. Management: Prenatal

  1. Address risk factors
    1. Tobacco Cessation
    2. Eliminate other negative habits
    3. Ensure adequate maternal weight gain
    4. Maximize Prenatal Care
    5. Reduce environmental stressors
  2. Maternal-Fetal Medicine Consultation Indications
    1. Maternal-Fetal Medicine Consultation recommended in all cases of IUGR
    2. Poor Nonstress Test
    3. Decreasing Biparietal diameter
    4. Oligohydramnios
    5. Abdominal circumference 4 weeks less than BPD
  3. Management based on Maternal-Fetal Medicine and objective data
    1. See Umbilical Artery Doppler End-Diastolic Velocity (EDV) as above
    2. Fetal Assessment monitoring as above

XI. Management: Small for Gestational Age Infants and Children

  1. Target 30% growth by 4 months, and 50% by age 7 years
  2. Follow weight, length and Head Circumference
    1. Obtain at least every three months for the first year, and then every 6 months
  3. Consult endocrinology for length <3% in those under age 2 years
  4. Monitor Developmental Milestones (cognitive, psychomotor)
  5. Annual Blood Pressure Monitoring starting at age 3 years

XII. Complications: Peripartum Risks of IUGR

  1. Meconium Aspiration
  2. Intrauterine Asphyxia
  3. Polycythemia
  4. Hypoglycemia
  5. Intraventricular Hemorrhage
  6. Hypoxic Ischemic Encephalopathy
  7. Necrotizing Enterocolitis
  8. Bronchopulmonary Dysplasia
  9. Late onset Neonatal Sepsis
  10. Persistent Pulmonary Hypertension
  11. Neonatal Jaundice
  12. Temperature Instability

XIII. Complications: Longterm Risks of IUGR

  1. Cerebral Palsy
  2. Developmental Delay
  3. Growth Delay
  4. Learning Disorder
  5. Cardiovascular Disease
  6. Impaired Insulin Resistance

XIV. Prevention

  1. No medications (e.g. Heparin, Vitamins) appear to reduce the risk of IUGR during pregnancy
  2. Aspirin prophylaxis is only effective in Preeclampsia to reduce IUGR risk

XV. References

  1. Gabbe (1996) Obstetrics, Churchill, p. 863-886
  2. Ahluwalia (2001) Obstet Gynecol 97:649-56 [PubMed]
  3. Westby (2021) Am Fam Physician 104(5): 486-92 [PubMed]

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Related Studies

Ontology: Fetal Growth Retardation (C0015934)

Definition (NCI_CTCAE) A disorder characterized by inhibition of fetal growth resulting in the inability of the fetus to achieve its potential weight.
Definition (NCI) A fetus that does not grow beyond the 10th percentile of conventionally accepted weight for gestational age.(NICHD)
Definition (CSP) abnormal fetal physical growth or growth potential at any gestational stage.
Definition (MSH) The failure of a FETUS to attain its expected FETAL GROWTH at any GESTATIONAL AGE.
Concepts Pathologic Function (T046)
MSH D005317
ICD9 764.90, 764.9
ICD10 P05.9
SnomedCT 22033007, 206166000, 156185006, 267337006, 268815007
English Growth Retardation, Fetal, Growth Retardation, Intrauterine, Intrauterine Growth Retardation, IUGR, Retardation, Fetal Growth, Retardation, Intrauterine Growth, Fetal growth retardation NOS, IUGR - Intraut growth retardat, Intrauterine growth retardatn., Slow fetal growth, unspecified, prenatal growth disorder, Fetal growth retardation, Fetal growth restriction, Intrauterine growth retardation (IUGR), intrauterine growth retardation, intrauterine growth retardation (diagnosis), Intrauterine growth restriction, Fet growth retard wtNOS, Fetal Growth Retardation [Disease/Finding], Foetal growth retardation, unspecified, Foetal growth restriction, Intrauterine growth retard, Fetal growth retardation, unspecified {weight}, Growth intrauterine retard, Fetal growth retardation, unspecified, Foetal growth retardation, Foetal growth retardation, unspecified {weight}, fetal growth retardation, growth intrauterine retardation, iugr, microsomia, intrauterine growth retard, poor fetal growth, iugrs, growth intrauterine restriction, intrauterine growth restriction, Intrauterine Growth Restriction, Fetal growth retardation, unspecified, unspecified [weight], Fetal growth retardation, unspecified [weight], Poor prenatal growth, (Fetal growth retardation NOS) or (intrauterine growth retardation), Insufficiency - placental, (Fetal growth retardation NOS) or (intrauterine growth retardation) (disorder), Fetal growth retardation NOS (disorder), Fetal Growth Restriction, Poor fetal growth state, Intrauterine growth retardation, Microsomia, Microsomic baby, IUGR - Intrauterine growth retardation, Poor fetal growth, FGR - Fetal growth retardation, Fetal growth retardation (disorder), fetal; growth retardation, fetal; poor growth, fetal; slow growth, poor; fetal growth, slow; fetal growth, Fetal growth retardation, NOS, Intrauterine growth retardation, NOS, Foetal growth retardation, NOS, Fetal Growth Retardation, Fetal growth retardation, unspecified weight, Intrauterine growth retardatio, intrauterine growth retardatio
Swedish Hämmad fostertillväxt
Finnish Sikiön kasvun hidastuminen
Russian RAZVITIIA PLODA ZADERZHKA VNUTRIMATOCHNAIA, PLODA RAZVITIIA ZADERZHKA, VNUTRIMATOCHNOGO RAZVITIIA PLODA ZADERZHKA, ВНУТРИМАТОЧНОГО РАЗВИТИЯ ПЛОДА ЗАДЕРЖКА, ПЛОДА РАЗВИТИЯ ЗАДЕРЖКА, РАЗВИТИЯ ПЛОДА ЗАДЕРЖКА ВНУТРИМАТОЧНАЯ
German Intrauterine Mangelentwicklung, nicht naeher bezeichnet, fetale Wachstumsverzoegerung, Wachstum, intraunterin, verzoegert, fetale Wachstumsverzoegerung, unspezifisch, fetale Wachstumsverzoegerung, unspezifisch {Gewicht}, intrauterine Wachstumsverzoegerung, intrauterines Wachstum verzoegert, Wachstumseinschraenkung des Foetus, Mikrosomie, Fetale Wachstumsretardierung, IUGR, Intrauteriner Wachstumsrückstand, Wachstumsrückstand, intrauteriner
Italian IUGR, Ritardo di crescita intrauterina, Ritardo di crescita fetale, non specificato, Ritardo di crescita fetale, non specificato {peso}, Restrizione della crescita fetale, Ritardo della crescita fetale, senza specificazione del peso, Distrofia fetale non specificata, Microsomia, Ritardo di crescita fetale
Korean 상세불명의 태아 성장 지연
Croatian FETUSNI RAST, RETARDACIJA
Dutch niet-gespecificeerde foetale groeivertraging {gewicht}, groei intra-uterien vertraagd, niet-gespecificeerde foetale groeivertraging, achterblijven van foetale groei, foetale groeivertraging, intra-uteriene groeivertraging, foetale groeibeperking, foetale groeivertraging, niet-gespecificeerd, {gewicht}, foetale groeivertraging, niet-gespecificeerd, microsomie, foetaal; groei-achterstand, foetaal; slechte groei, foetaal; trage groei, slecht; foetale groei, traag; foetale groei, Trage foetale groei, niet gespecificeerd, Foetale groeistoornis, Groeistoornis, foetale, Groeivertraging, intra-uteriene, Intra-uteriene groeivertraging
Spanish Crecimiento intrauterino retardado, Retraso en el crecimiento intrauterino, Retraso en el crecimiento fetal, no especificado (peso), Retardo del crecimiento fetal (con peso) no especificado, Retraso del crecimiento fetal, Restricción del crecimiento fetal, Retraso en el crecimiento fetal, Retraso en el crecimiento fetal, no especificado, Retardo del crecimiento fetal no especificado, Microsomía, retardo de crecimiento fetal, SAI (trastorno), retardo de crecimiento fetal, SAI, RCIU, retardo del crecimiento fetal (trastorno), retardo del crecimiento fetal, retardo del crecimiento intrauterino, retraso de crecimiento fetal, bebé microsómico, estado de crecimiento fetal pobre, microsomía, Retardo del Crecimiento Fetal, Retardo del Crecimiento Intrauterino
Portuguese Atraso do crescimento fetal, Atraso do crescimento fetal NE, Atraso de crescimento intra-uterino, Atraso do crescimento fetal NE (peso), Restrição do crescimento fetal, Microsomia, Retardo do Crescimento Intrauterino, RCIU, Retardo do Crescimento Fetal
French Retard de croissance foetale, non précisé {poids}, Retard de croissance foetale, non précisé, Retard de croissance foetale, poids non précisé, Retard de croissance intra-utérine, Restriction de croissance foetale, Microsomie, Hypotrophie foetale, Retard de croissance foetale, Retard de croissance intra-utérin, Retard du développement foetal, RCIU, Retard de croissance intra-utérin (RCIU)
Japanese ﾀｲｼﾞﾊﾂｲｸﾁｴﾝ, 胎児発育遅延、体重詳細不明, 胎児発育遅延、詳細不明, 胎児発育遅延, ｼｷｭｳﾅｲﾀｲｼﾞﾊﾂｲｸﾁｴﾝ, ﾀｲｼﾞﾊﾂｲｸﾁｴﾝﾀｲｼﾞｭｳｼｮｳｻｲﾌﾒｲ, ﾀｲｼﾞﾊﾂｲｸﾁｴﾝｼｮｳｻｲﾌﾒｲ, ｼｮｳﾀｲｼｮｳ, 小体症, 子宮内成長遅滞, 胎児成長遅滞, 子宮内胎児発育遅延, 成長遅滞-子宮内
Czech Intrauterinní růstová retardace, Růstová retardace plodu, blíže neurčená (váha), Růstová retardace plodu, Retardace intrauterinního růstu, Opoždění vývoje plodu, Retardace růstu plodu, blíže neurčená (váha), Retardace růstu plodu, Opožděný vývoj plodu, Růstová retardace plodu, blíže neurčená, Zpomalení intrauterinního růstu, Retardace růstu plodu, blíže neurčená, Mikrosomie, nitroděložní růstová retardace, fetální růstová retardace, IUGR, intrauterinní růstová restrikce plodu, fétus - růstová retardace, intrauterinní růstová retardace
Polish Hipotrofia płodu wewnątrzmaciczna, Opóźnienie rozwoju płodu
Hungarian Intrauterin növekedési retardatio, Intrauterin növekedési visszamaradás, Magzati növekedés retardatiója, Magzati növekedés korlátozása, Magzati növekedés retardatiója, nem meghatározott, Magzati növekedési retardatio, nem meghatározott {súly}, Microsomia, Növekedési intrauterin visszamaradás, Magzat növekedés korlátozása, Magzati növekedés retardatiója, nem meghatározott {súly}, Magzati növekedési retardatio, Magzati növekedési retardatio, nem meghatározott
Norwegian Føtal vekstretardasjon, Intrauterin veksthemming, Hemmet fostervekst, Hemmet føtal vekst, Veksthemming, intrauterin
Derived from the NIH UMLS (Unified Medical Language System)

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