Gorovitz & Borten, P.C.
Attorneys at Law

550 Cochituate Road, Suite 25
Framingham, Massachusetts
Tel: (781) 890-9095
Growth Restriction in Utero
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:

  • Chronic hypertension
  • Pregnancy induced hypertension
  • Smoking
  • Substance abuse (alcohol, drugs)
  • Protein calorie malnutrition
  • Diabetes
  • Placental insufficiency
  • Preeclampsia
  • Cyanotic heart disease
  • Hemoglobinopathy
  • Placenta abruptio
  • Placenta previa

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

  • Perinatal asphyxia
  • Persistent pulmonary hypertension
  • Respiratory distress
  • Meconium aspiration
  • Hypothermia
  • Hypoglycemia
  • Hypocalcemia
  • Polycythemia
  • Decreased immunity

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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