Review
Obstetrics
Intrauterine growth restriction: new concepts in antenatal surveillance, diagnosis, and management

https://doi.org/10.1016/j.ajog.2010.08.055Get rights and content

Intrauterine growth restriction (IUGR) remains one of the main challenges in maternity care. Improvements have to start from a better definition of IUGR, applying the concept of the fetal growth potential. Customized standards for fetal growth and birthweight improve the detection of IUGR by better distinction between physiological and pathological smallness and have led to internationally applicable norms. Such developments have resulted in new insights in the assessment of risk and surveillance during pregnancy. Serial fundal height measurement plotted on customized charts is a useful screening tool, whereas fetal biometry and Doppler flow are the mainstay for investigation and diagnosis of IUGR. Appropriate protocols based on available evidence as well as individualized clinical assessment are essential to ensure good management and timely delivery.

Section snippets

New tools and new insights

In modern epidemiological research, the standard for birthweight for gestation has been refined to be able to assess birthweight not against the average of the population but against an individual growth potential calculated for each baby in each pregnancy.

This is based on 3 principles.6, 7 First, the standard is adjusted or customized for sex as well as maternal characteristics such as height, weight, parity, and ethnic origin on the principle that one size does not fit all.8 The stepwise

Previous history of growth restriction or stillbirth

Women with a previous growth-restricted baby have a 50% increased risk of severe growth restriction in the current pregnancy,27 and serial third-trimester assessment for this indication is common practice. A history of stillbirth is also an accepted indication for intensive antepartum surveillance because more than half of normally formed stillbirths are associated with IUGR.22 Stillbirths before 32 weeks' gestation have a particularly strong association with IUGR.28 Previous stillbirth would

Diagnosis of IUGR

Current thinking on the natural history of growth restriction differentiates between early-onset and late-onset forms,100 which have different biochemical, histological, and clinical features.101 Whereas the former is usually diagnosed with an abnormal umbilical artery Doppler and is frequently associated with preeclampsia, the latter is more prevalent, shows less change in umbilical flow pattern, and has a weaker association with preeclampsia.101

Assessment of the IUGR fetus

Because no treatment has been demonstrated to be of benefit for FGR,124, 125, 126, 127 the assessment of fetal well-being and timely delivery remains as the main strategy for management. Fetal well-being tests could be classified as chronic or acute. Whereas, the former becomes progressively abnormal because of increasing hypoxemia and/or hypoxia, the latter correlates with acute changes occurring in advanced stages of fetal compromise, characterized by severe hypoxia and metabolic acidosis,

Timing of delivery

IUGR is one of the most common pregnancy complications and substantially increases the prospective risk of adverse outcome. Yet according to pregnancy audits, most instances of IUGR are not detected as such antenatally. Modern obstetric care needs to raise the level of awareness of the importance of this condition, and establish evidence-based protocols for improved surveillance.

Because the only current treatment for IUGR is delivery, the main consideration needs to be appropriate timing,

References (154)

  • Z. Alfirevic et al.

    Doppler ultrasonography in high-risk pregnancies: systematic review with meta-analysis

    Am J Obstet Gynecol

    (1995)
  • J. Villar et al.

    Preeclampsia, gestational hypertension and intrauterine growth restriction, related or independent conditions?

    Am J Obstet Gynecol

    (2006)
  • J.W. Weeks et al.

    Antepartum surveillance for a history of stillbirth: when to begin?

    Am J Obstet Gynecol

    (1995)
  • R.K. Freeman et al.

    The significance of a previous stillbirth

    Am J Obstet Gynecol

    (1985)
  • M. Gordon et al.

    Perinatal outcome and long-term follow-up associated with modern management of diabetic nephropathy

    Obstet Gynecol

    (1996)
  • E.A. Nohr et al.

    Combined associations of prepregnancy body mass index and gestational weight gain with the outcome of pregnancy

    Am J Clin Nutr

    (2008)
  • T. Farrell et al.

    The effect of body mass index on three methods of fetal weight estimation

    BJOG

    (2002)
  • L.M. Hollier et al.

    Outcome of twin pregnancies according to intrapair birth weight differences

    Obstet Gynecol

    (1999)
  • S. Ong et al.

    The creation of twin centile curves for size

    BJOG

    (2002)
  • W. Giles et al.

    The Doppler assessment in multiple pregnancy randomised controlled trial of ultrasound biometry versus umbilical artery Doppler ultrasound and biometry in twin pregnancy

    BJOG

    (2003)
  • L. Dugoff et al.

    First-trimester maternal serum PAPP-A and free-beta subunit human chorionic gonadotropin concentrations and nuchal translucency are associated with obstetric complications: a population-based screening study (the FASTER Trial)

    Am J Obstet Gynecol

    (2004)
  • N. Lepage et al.

    Association between second-trimester isolated high maternal serum maternal serum human chorionic gonadotropin levels and obstetric complications in singleton and twin pregnancies

    Am J Obstet Gynecol

    (2003)
  • K.D. Wenstrom et al.

    The effect of low-dose aspirin on pregnancies complicated by elevated human chorionic gonadotropin levels

    Am J Obstet Gynecol

    (1995)
  • M. Vainio et al.

    Low dose acetylsalicylic acid in prevention of pregnancy-induced hypertension and intrauterine growth retardation in women with bilateral uterine artery notches

    BJOG

    (2002)
  • J.M. Belizan et al.

    Diagnosis of intrauterine growth retardation by a simple clinical method: measurement of uterine height

    Am J Obstet Gynecol

    (1978)
  • V. Grover et al.

    Altered fetal growth: antenatal diagnosis by symphysis-fundal height in India and comparison with Western charts

    Int J Gynaecol Obstet

    (1991)
  • K. Morse et al.

    Fetal growth screening by fundal height measurement

    Best Pract Res Clin Obstet Gynaecol

    (2009)
  • M. Mongelli et al.

    Symphysis-fundus height and pregnancy characteristics in ultrasound-dated pregnancies

    Obstet Gynecol

    (1999)
  • L.S. Bakketeig et al.

    Randomised controlled trial of ultrasonographic screening in pregnancy

    Lancet

    (1984)
  • C. David et al.

    Receiver-operator characteristic curves for the ultrasonographic prediction of small-for-gestational-age fetuses in low-risk pregnancies

    Am J Obstet Gynecol

    (1996)
  • J.P. Newnham et al.

    An evaluation of the efficacy of Doppler flow velocity waveform analysis as a screening test in pregnancy

    Am J Obstet Gynecol

    (1990)
  • D. McKenna et al.

    A randomized trial using ultrasound to identify the high-risk fetus in a low-risk population

    Obstet Gynecol

    (2003)
  • S. Kady et al.

    Perinatal mortality and fetal growth restriction

    Best Pract Res Clin Obstet Gynaecol

    (2004)
  • B. Jacobsson et al.

    Cerebral palsy and restricted growth status at birth: population-based case-control study

    BJOG

    (2008)
  • M. Hepburn et al.

    An audit of the detection and management of small-for-gestational age babies

    Br J Obstet Gynaecol

    (1986)
  • B. Backe et al.

    Effectiveness of antenatal care: a population based study

    Br J Obstet Gynaecol

    (1993)
  • M. Mongelli et al.

    A customized birthweight centile calculator developed for an Australian population

    Aust N Z J Obstet Gynaecol

    (2007)
  • GROW (Gestation Related Optimal Weight)—software for customised centilesGestation Network

  • F. Figueras et al.

    Customized birthweight standards accurately predict perinatal morbidity

    Arch Dis Child Fetal Neonatal Ed

    (2007)
  • L.M. McCowan et al.

    Customized birthweight centiles predict SGA pregnancies with perinatal morbidity

    BJOG

    (2005)
  • C.L. de Jong et al.

    Fetal weight gain in a serially scanned high-risk population

    Ultrasound Obstet Gynecol

    (1998)
  • M. Mongelli et al.

    Longitudinal study of fetal growth in subgroups of a low-risk population

    Ultrasound Obstet Gynecol

    (1995)
  • J. Gardosi

    Ultrasound biometry and fetal growth restriction

    Fetal Matern Med Rev

    (2002)
  • A. Dua et al.

    An investigation into the applicability of customised charts for the assessment of fetal growth in antenatal population at Blackburn, Lancashire, United Kingdom

    J Obstet Gynaecol

    (2006)
  • M. Illa et al.

    Growth deficit in term small-for-gestational fetuses with normal umbilical artery Doppler is associated with adverse outcome

    J Perinat Med

    (2009)
  • J. Gardosi et al.

    Classification of stillbirth by relevant condition at death (ReCoDe): population based cohort study

    BMJ

    (2005)
  • P.G. Lindqvist et al.

    Does antenatal identification of small-for-gestational age fetuses significantly improve their outcome?

    Ultrasound Obstet Gynecol

    (2005)
  • J.F. Stratton et al.

    Are babies of normal birth weight who fail to reach their growth potential as diagnosed by ultrasound at increased risk?

    Ultrasound Obstet Gynecol

    (1995)
  • E.A. Reece et al.

    Pregnancy outcomes among women with and without diabetic microvascular disease (White's classes B to FR) versus non-diabetic controls

    Am J Perinatol

    (1998)
  • J.A. Rowan et al.

    Customised birthweight centiles are useful for identifying small-for-gestational-age babies in women with type 2 diabetes

    Aust N Z J Obstet Gynaecol

    (2009)
  • Cited by (339)

    View all citing articles on Scopus
    View full text