Intrauterine growth restriction (IUGR) is defined as a fetal weight below the 10th percentile for gestational age, small for gestational age (SGA) with no congenital abnormalities. Intrauterine growth restriction (IUGR) is also defined as the failure to achieve full fetal growth potential with the consequent increased risk of perinatal morbidity and mortality. Fetal growth restriction reflects either an unfriendly uterine environment or a chromosomal abnormality. Monitoring, recognizing, correcting and improving fetal well-being is the medical provider's responsibility. Failure to monitor the uterine environment or intervene to protect the fetal well being is a frequent cause of medical malpractice.
The perinatal mortality for IUGR infants is 6 to 10 times greater than for appropriately grown fetuses. Approximately 40% of IUGR are at high risk of potentially preventable perinatal death. It is these preventable perinatal death that requires close attention by the obstetrical team. The ultimate goal is to deliver a newborn with the best chances to survive and thrive.
Causes of IUGR can be either fetal or maternal. Fetal causes are essentially congenital malformations (trisomy 13, trisomy 18, triploidy) or infectious in origin (cytomegaloviral infection, toxoplasmosis, intrauterine infection). Causative factors for growth restriction should be investigated in-utero. Maternal causes of IUGR include:
Pregnancy induced hypertension
Substance abuse (alcohol, drugs)
Protein calorie malnutrition
Cyanotic heart disease
Intrauterine growth restriction (IUGR) is further categorized into symmetric versus asymmetric growth. The symmetric growth restricted infant is affected early in gestation and the entire fetus is proportionally small for gestational age. Most measurements (head, abdomen, length and weight) are below the 10th percentile for gestational age. The prognosis for these infants (if born alive) is poor. Approximately 25% of these fetuses have a genetic abnormality incompatible with life.
The asymmetric growth restricted infant is likely to have the growth restriction due to utero-placental insufficiency. The fetal abdomen is small but the head and extremities are normal or near normal (head-sparing effect). The asymmetric growth is thought to be a fetal compensatory mechanism in response to poor placental perfusion. It is estimated that up to 70% of IUGR is of the asymmetric variety. IUGR is associated with an increased risk for mental as well as physical problems after birth.
IUGR can and should be diagnosed at the earliest possible prenatal evaluation. Physical examination alone can misdiagnose up to 30% of IUGR. Key parameters for diagnosing IUGR include estimated fetal weight, volume of amniotic fluid and maternal blood pressure assessments. Prompt diagnosis can be accomplished by appropriate testing with:
Biometric studies (ultrasound)
Amniotic fluid volume
Umbilical artery Doppler
Uterine artery Doppler
Middle cerebral artery Doppler
Venous Doppler waveforms
Ultrasound studies should be obtained in the middle of the second trimester of pregnancy. Fetal ultrasounds performed every 4 to 6 weeks were found most useful in identifying fetal growth restriction. Assessment of fetal well-being in- utero also requires the use of non-stress testing and biophysical profiles at regular intervals.
With no effective treatment to reverse fetal growth restriction, timing of the delivery is paramount. Antenatal management of fetal growth restriction requires balancing the benefit of the fetus remaining in-utero with the risks of delivering a premature infant. When the risk to the fetus of remaining in-utero are greater than birth, immediate delivery should be accomplished. Advances in neonatal care at times outweighs the benefit of continuing the pregnancy for another few days or weeks. Risks to a newborn associated with intrauterine growth restriction include:
Persistent pulmonary hypertension
If your child was born with IUGR and you were not given the option to undergo appropriate testing, Dr. Borten and the Boston area medical malpractice attorneys at Gorovitz & Borten can help you assert your rights and get the compensation you deserve.
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