APGO Educational Objectives: 

Define intrauterine growth restriction and describe the associated risk factors, recognized causes, methods used in diagnosis, methods used in management and associated maternal/fetal morbidities.


 

 

 

 

 

 

 

Recommended Reading Assignment:  

  1. Intrauterine Growth Retardation, Chapter 19 in Obstetrics and Gynecology, 3rd Edition, Beckmann, et al, pp. 253-259, 1998


 

 

 

 

 

 

 

 

 

Questions:

  1. Identify the clinical facts from your history that may be etiologic factors in this presumed diagnosis of IUGR. What additional historical items might be elicit from this patient that may be contributing to a potential diagnosis of IUGR? List your etiologic factors into maternal or fetal categories.
  2. What physical findings in this patient are suspicious/confirmatory for rendering a clinical diagnosis of IUGR?
  3. Discuss the limitations and accuracy of making this diagnosis of IUGR on your historical/physical findings at your first prenatal visit today.


You and the patient agree to order an ultrasound examination of the pregnancy. The ultrasound report reads:  Viable singleton fetus in vertex presentation. Grade III anterior placenta with borderline amniotic fluid volume. A limited fetal anatomic survey appears normal. Biophysical parameters are reassuring. Fetal morphometrics include:

Percentile for 30 weeks
Biparietal Diameter:         
71 mm  40%
Head Circumference:            260 mm 30%
Abdominal Circumference:        205 mm 05%
Femur Length:             
53 mm 45%
Estimated Fetal Weight:            
850 gms 10%
Impression: Sonographic findings c/w severe asymmetric IUGR.
  1. Divide your list of IUGR etiologies further into symmetric vs. asymmetric classification. Discuss the pathophysiology of each of these classifications in general terms. Are they useful models in the diagnosis/management of IUGR pregnancies?
  2. What additional non-invasive testing can we order to confirm or disprove some of our proposed etiologic factors in this case? What invasive procedures may be helpful if we are concerned this is a severe case of IUGR? Do you want to obtain any ancillary consultations from your colleagues/allied health professionals?

Your initial work-up results are non-contributory and you inform your patient of these results. The patient asks you to outline your management plan for the remainder of the pregnancy and what is the short-term/long-term prognosis for her child.

  1. Discuss the neonatal implications of the diagnosis of IUGR.
  2. Define the ultimate goal of your management plan. Discuss the risks and benefits of active intervention for this preterm fetus. Discuss the risk and benefits of expectant management towards term with continued ultrasound surveillance.
  3. Presuming you decide to recommend expectant management, what additional tests would you order to ensure continued fetal well-being? What would be the end-points of this management plan to prompt a delivery?