intrauterine growth restriction

Question 1

A 22 yo G1 P0 at 34 weeks comes to you for a routine prenatal appointment. She states she feels well. She reports good fetal movement and denies: rupture of membranes, vaginal bleeding, or abdominal pain.
You note her fundal height is 30 cm.

Answer 1

Ultrasound demonstrates symmetric intrauterine growth restriction. You order TORCH titers. Results are positive for cytomegalovirus. You counsel the patient about the diagnosis and refer her to a maternal-fetal medicine specialist.

Question 2

intrauterine growth restriction (IUGR)

Answer 2

-estimated fetal wt at or below 10th percentile for GA by US
-Suspect if discrepancy of fundal ht and GA
-ex. 32 weeks with fundal ht of 29 cm -> US to r/o IUGR

-Fetal biometry is performed to determine estimated fetal weight (EFW)
-It includes measurement of:
-Head circumference
-Biparietal diameter
-Abdominal circumference
-Femur length

-These measurements then are used to calculate EFW
-dx of IUGR is also based on Doppler measurement of blood flow through umbilical vessels

Question 3

etiology of IUGR

Answer 3

-Underlying maternal conditions
-HTN
-Renal, endocrine, autoimmune, infectious diseases
-Substance use

-Genetic conditions
-Placental abnormalities
-Umbilical cord abnormalities

Question 4

abdominal circumference

Answer 4

femur length

Question 5

maternal risk factors for IUGR

Answer 5

-!Hypertensive disorders of pregnancy
-!Renal insufficiency
-!Cocaine or amphetamine use
-!Infectious diseases (toxoplasmosis, rubella, cytomegalovirus, herpes, syphilis)

-dont need to know below
Pregestational diabetes mellitus
Autoimmune disease (SLE)
Cyanotic cardiac disease
Antiphospholipid antibody syndrome

Question 6

fetal risk factors for IUGR

Answer 6

-twin or higher order multiple gestation
-teratogen exposure
-genetic disorders
-placental and umbilical cord disorders
-twin to twin transfusion syndrome in monochorionic gestations

Question 7

intrauterine growth restriction

Answer 7

-Most due to decrease uteroplacental blood flow; may also involve conditions of placenta, uterus, fetus, or patient (see above)

->

-May be “head-sparing” or asymmetric
-more commonly assoc with HTN DISORDER

->

-may be symmetric
-more commonly assoc with INFECTION (torch)

Question 8

symmetrical and asymmetrical intrauterine growth restriction

Answer 8

Question 9

symmetric IUGR

Answer 9

-Associated with the following maternal infections during pregnancy:
-Toxoplasmosis
-Rubella
-Cytomegalovirus
-Herpes

Question 10

sequelae of IUGR

Answer 10

-passage of meconium and meconium aspiration

-sequelae of prematurity:
-Necrotizing enterocolitis
-Retinopathy of prematurity
-Long term pulmonary disease
-Decreased Apgar scores
-Hypoxic brain injury

Question 11

management of IUGR

Answer 11

-serial US to monitor fetal growth and amniotic fluid index
-r/o TORCH infections -> obtain TORCH titers
-doppler velocimetry of cord vessels -> reversed end-diastolic flow is assoc with increased risk of fetal mortality
-biophysical profiles q 2-4wks

-Indication for delivery depends on:
-Underlying etiology of IUGR
-Estimated gestational age
-Results of f/u studies
-delivery is indicated from 32-38wks depending

Question 12

by what gestational age should fetuses with IUGR be delivered

Answer 12

-30
-32
-34
-36
-38!!!!!!!!! (max)