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IUGR
TYPES:

Symmetrical –20%
Asymmetrical-80%

SYMMETRICAL: where all the fetal parameters are reduced i.e. BPD, FL, HC, AC and
usually presents as early as the first trimester or in the final trimester.(when severe
,asymmetrical IUGR may convert to symmetrical)

Causes: Include (a) Low Genetic growth potential

(b) Severe maternal malnutrition
(c) Intra-uterine Infection
(d) Chromosomal & Congenital anomalies

ASYMMETRICAL: where growth retardation effects abdominal circumference while sparing

the other parameters .A small AC is present since liver being a storage organ for glycogen is
effected & hence reduced in size.

Causes: It is usually caused by placental insufficiency in maternal diseases like Chronic

Hypertension, Cardiac or renal disease, Abruptio Placentae & Multiple pregnancy.
Asymmetrical IUGR more commonly presents after 30 wks & if severe may later lead to
symmetrical IUGR.

CLINICALLY SUSPISCIOUS GROUP INCLUDES:

1. Previous history of growth retarded fetus.

2. Chronic hypertension
3. Insulin dependent Diabetes mellitus.
4. Extremely poor weight gain.
5. Alcohol, Drug abuse, Cigarette smoking
In clinically suspicious people a first trimester ultrasound is suggested for
proper dating to pick up cases of symmetrical IUGR

DIAGNOSTIC CRITERION:

1. FETAL WEIGHT: A fetus with fetal weight below 10th percentile is considered growth-
retarded .The best estimation is with a formula, which incorporates multiple parameters such
as BPD, HC, and AC.
The drawback with fetal weight estimation is that it ignores the genetic growth potential .For
e.g.: a fetus of 2.8 kg may be of normal weight since it has grown to its potential while a 3 kg
fetus may be an IUGR fetus since its genetic growth potential may be of 3.5 kg.

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2. ABDOMINAL CIRCUMFERENCE: is a poor indicator of gestational age but is the most

sensitive single indicator of IUGR .AC falling below 2SD is likely to suggest IUGR.
However, for assessing IUGR by AC menstrual age should be known.

MEASUREMENT OF AC:-should be measured where the left umbilical vein is seen to enter the portal
sinus(PV) --- Hockey stick appearance

3. HC: AC RATIO: It is a well known fact that an early fetal head is larger than abdomen &
as the pregnancy progresses it gradually attains the normal adult shape i.e. the abdomen
becomes larger than head. Therefore the HC: AC ratio goes on declining with advancement
of pregnancy. The reverse indicates IUGR.
Once the HC: AC ratio is calculated, it can be estimated whether the ratio falls in the normal
range by referring to standard charts. If the ratio is normal, it usually suggests normal fetus
(98% accuracy). However, the drawback is that when the ratio is abnormal, 35% of cases
may still not have IUGR. (High false positive). In addition, menstrual age must be known.

4. FL/AC RATIO: This ratio can be used for assessing IUGR anytime after 20 weeks even
when the menstrual age is not known. A ratio above 24% indicates IUGR. IUGR can be ruled
out with 90% confidence if the ratio is normal. However, with abnormal ratio approx. 60%
may still not have IUGR. (High false positive).

5. AMNIOTIC FLUID: It has been seen that oligohydramnios is commonly associated with
IUGR. Most of the studies have found an accuracy of 50-60% detection (of IUGR) when
oligohydramnios was used as the criterion. In most of these cases, oligohydramnios was

diagnosed by the criterion of maximum fluid pocket of 1 cm. Less stringent criterion of
Oligohydramnios can be known by AFI .(AMNIOTIC FLUID INDEX)

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AFI is the sum of the largest pocket of the four quadrants, While calculating AFI transducer
should be perpendicular to the floor, the largest vertical pocket should be measured &
maternal uterine wall should not be included. Oligohydramnios is suggested with AFI<8 CM.

6.TRANSCEREBELLAR DIAMETER: It has been believed by many that trans-cerebellar

diameter is not effected by IUGR & thus it can be used as a reliable indicator of gestational
age even in cases of IUGR. Between 15-24 weeks TCD in mm is approx.equal to gestational
age in weeks A ratio of TCD: AC can be used to identify cases of IUGR..The ratio is
expressed as a percentage.

Role of TCD: AC ratio in IUGR—It has been found that normal fetuses without IUGR had a
ratio of 13.1 + 0.68. In IUGR fetuses with birth wt. in –1SD range the ratio was 14.9+ 1.9
while those with birth wt. in –2SD range the ratio was 16.4+ 2.38 .The positive predictive
value of TCD:AC ratio in predicting IUGR was approx. 90 % while negative predictive
value was approx. 80 %.

7.BPD & FL: are poor indicators of IUGR & are effected very late.

8.PLACENTAL GRADE & THICKNESS: It has been found that grade III placenta before
34 weeks specially when associated with placental thickness of less than 1.5 cm has a
reasonably good predictive value for IUGR.

Institute Of Ultrasound Training,New Delhi,India