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Obstetric management of intrauterine growth restriction

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The aim of obstetric management is to identify growth-restricted foetuses at risk of severe intrauterine hypoxia, to monitor their health and to deliver when the adverse outcome is imminent. After 30–32 gestational weeks, a Doppler finding of absent or reverse end-diastolic flow in the umbilical artery of a small-for-gestational age foetus is in itself an indication for delivery. In very preterm foetuses, the intrauterine risks have to be balanced against the risk of prematurity. All available diagnostic information (e.g., Doppler velocimetry of umbilical artery, foetal central arteries and veins and of maternal uterine arteries; foetal heart rate with computerised analysis of short-term variability; amniotic fluid amount; and foetal gestational age-related weight) should be collected to support the timing of delivery. If possible, the delivery should optimally take place before the onset of late signs of foetal hypoxia (pathological foetal heart rate pattern, severely abnormal ductus venosus blood velocity waveform, pulsations in the umbilical vein).

Section snippets

Background

Intrauterine growth restriction (IUGR) is associated with increased perinatal mortality and morbidity1, and, as shown more recently, also with long-term morbidity and predisposition for development of chronic diseases in adult age.2 Among cases of unexplained intrauterine death, a significant proportion of foetuses are small-for-gestational age (SGA).3 Similarly, among post-term pregnancies with adverse outcome, SGA foetuses predominate.4 Thus, the goal for obstetric management of pregnancies

Identification of IUGR foetuses

The diagnosis of an SGA foetus is usually given by comparing the ultrasonically estimated foetal weight or standard foetal dimensions (e.g., abdominal circumference) with the expected values, according to the standard curves of intrauterine growth. A prerequisite is a reliably estimated gestational age; at present, the most accurate estimation of gestational age is the ultrasound dating based on measurement of foetal size in early gestation. The ultrasound evaluation of foetal growth in the

Doppler velocimetry

Of the biophysical methods used to monitor foetal health in IUGR, Doppler velocimetry has the best predictive value.*35, 42, 43 It allows the clinician to evaluate the circulation on both sides of the placenta and to judge on the foetal adaptive circulatory changes as a response to developing hypoxia. The Doppler results are most informative if they can be collected longitudinally, thus enabling judgement on the possible progress of foetal hypoxia. The frequency of repeated Doppler examinations

Clinical management of IUGR pregnancies

As mentioned above, the possibilities of efficiently treating growth-restricted foetuses in utero are very limited, not to say non-existent. Thus, the clinical management aims to deliver the IUGR foetus in time to avoid hypoxic damage to the foetus and eventually intrauterine death. At present, the principles of clinical management in IUGR comprise detection of an SGA foetus, the monitoring of foetal health and delivery for a foetal indication in an appropriate manner at the correct time. In

Follow-up of growth-restricted infants

It has been shown in many studies that SGA newborns often have suboptimal post-natal development.61, 62 In IUGR newborns that have had abnormal intrauterine flow, neurological and cognitive development was found to be impaired up to the young adult age.*63, *64 The growth-restricted individuals showed also minor changes in their visual65 and cardiovascular66 functions. Studies with magnetic resonance imaging of the brain of growth-restricted infants reported decreased volume of cerebral

Summary — Clinical Management of IUGR

The majority cases have a placental cause. Therefore, clinically, the IUGR foetuses are usually identified as SGA foetuses with abnormal placental haemodynamics at Doppler ultrasound velocimetry. The possibilities of treating IUGR in utero are very limited; the clinical management has to rely on monitoring foetal health and choosing the appropriate time for delivery to avoid intrauterine demise or severe hypoxic damage to the foetus. Doppler ultrasound velocimetry is at present the most

Conflict of interest

No conflict of interest to declare.

Practice points

  • Intrauterine growth restriction is an important complication of pregnancy with possible adverse consequences for the outcome of pregnancy, the perinatal period and for the long-term postnatal health of the foetuses

  • Ultrasound dating and foetal biometry are prerequisites for detection of SGA foetuses

  • Doppler velocimetry is the method of choice for monitoring growth-restricted foetuses and for timing of delivery

  • Caesarean section is indicated in many

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