Management Of Intrauterine Growth Restriction Research Articles

The Reproducibility of 3D power Doppler in Intrauterine Growth Restriction

Objective: it is to examine the reproducibility of 3D power Doppler in the management of intrauterine growth restriction compared with the conventional 2d Doppler. Patients and Methods: This study was performed between Jan 2021 and Feb 2022 and included 100 pregnant women recruited from outpatient clinic at Elgalaa Teaching Hospital, 3D power Doppler US was done for assessment of IUGR and compare the findings with 2D Doppler. Results: it is found that 3D Power Doppler parameters were significant in prediction of poor neonatal outcome regarding development of respiratory complications, neurological complications and IUFD as complications to IUGR comparing to 2D colour Doppler parameters which were non-significant in these cases. Our results also showed that the only parameter of 2D Colour Doppler that showed significance and positive correlation to birth weight among these cases was Middle Cerebral Artery Pulpability Index. Conclusion: 2D Doppler flow-velocity waveforms are of limited value in the prediction of poor neonatal outcome in IUGR except for MCAPI. 3D power Doppler was superior in the diagnosis and prediction of neonatal outcome.

Management of Intra-Uterine Growth Restriction by Ayurvedic Regime: A Case Report

Maternal nutrition and congenital malformation are considered as very important factors for intra uterine growth restriction. Present case deals with these two factors in parallel way. A 32 years young lady second gravida, G2P0A1, housewife, residence of Jaipur, came to NIA OPD with complaint of amenorrhea since a month. According to patient her last menstrual period was on 3/3/20. Her antenatal care was continued in NIA OPD. First fetal wellbeing scan reveals mild ventriculomegaly so she was advised for second level scan and quadruple marker but due to low socioeconomic condition patient was not able to do second level anomaly scan and she continued her pregnancy on her own risk. After 7 months she came to us with the complaints of decreased fetal movements. Fundal height corresponding to period of gestation and fetal heart sound was present which was regular. A color doppler was advised which shows normal fetoplacental and uteroplacental circulation, fetal weight was normal according to period of gestation. On the eighth month the fundal height was found decreased along with maternal weight decreased by 1kg. She was suspected for IUGR and planned for Ksheerbasti. After four episodes Ksheer basti on the 36 weeks of gestation, mother had significant weight gain of 2 kg along with increase in fundal height. USG was done which reveals Single live intra uterine pregnancy of 33 weeks 2 days with lumbar spina bifida with meningomyelocele, CHIARI-II brain malformation, EFW– 2282gm. She delivered a live female child of 2300gm through normal vaginal delivery at maternity hospital. Child was having severe form of myelomeningocele with brain malformation.

Minimum evidence-based care in intrauterine growth-restricted fetuses and neonatal prognosis.

Introduction: There is clear evidence that fetuses with intrauterine growth restriction (IUGR) do not receive the minimum evidence-based care during their antenatal management. Considering that optimal management of IUGR may reduce neonatal morbi-mortality in IUGR, the objective of the present study was to evaluate the impact of antenatal management of IUGR according to the recommendations of the French college of gynecologists and obstetricians (CNGOF) on the neonatal prognosis of IUGR fetuses. From a historical cohort of 31,052 children, born at the Femme Mère Enfant hospital (Lyon, France) between January 1, 2011 and December 31, 2017, we selected the population of IUGR fetuses. The minimum evidence-based care (MEC) in the antenatal management of fetuses with IUGR was defined according to the CNGOF recommendations and neonatal prognosis of early and late IUGR fetuses were assessed based on the whether or not they received MEC. The neonatal prognosis was defined according to a composite criterion that included neonatal morbidity and mortality. A total of 1020 fetuses with IUGR were studied. The application of MEC showed an improvement in the neonatal prognosis of early-onset IUGR (p = 0.003), and an improvement in the neonatal prognosis of IUGR born before 32weeks (p = 0.030). Multivariate analysis confirmed the results showing an increase in neonatal morbi-mortality in early-onset IUGR in the absence of MEC with OR 1.79 (95% CI 1.01-3.19). Diagnosed IUGR with MEC had a better neonatal prognosis when born before 32weeks. Regardless of the birth term, MEC improved the neonatal prognosis of fetuses with early IUGR. Improvement in the rate of MEC during antenatal management has a significant impact on neonatal prognosis.

Insights into intrauterine growth restriction based on maternal and umbilical cord blood metabolomics

Intrauterine growth restriction (IUGR) is a fetal adverse condition, ascribed by limited oxygen and nutrient supply from the mother to the fetus. Management of IUGR is an ongoing challenge because of its connection with increased fetal mortality, preterm delivery and postnatal pathologies. Untargeted nuclear magnetic resonance (1H NMR) metabolomics was applied in 84 umbilical cord blood and maternal blood samples obtained from 48 IUGR and 36 appropriate for gestational age (AGA) deliveries. Orthogonal projections to latent structures discriminant analysis (OPLS-DA) followed by pathway and enrichment analysis generated classification models and revealed significant metabolites that were associated with altered pathways. A clear association between maternal and cord blood altered metabolomic profile was evidenced in IUGR pregnancies. Increased levels of the amino acids alanine, leucine, valine, isoleucine and phenylalanine were prominent in IUGR pregnancies indicating a connection with impaired amino acid metabolism and transplacental flux. Tryptophan was individually connected with cord blood discrimination while 3-hydroxybutyrate assisted only maternal blood discrimination. Lower glycerol levels in IUGR samples ascribed to imbalance between gluconeogenesis and glycolysis pathways, suggesting poor glycolysis. The elevated levels of branched chain amino acids (leucine, isoleucine and valine) in intrauterine growth restricted pregnancies were linked with increased insulin resistance.

Clinical efficacy of ayurveda treatment modalities in the management of garbhashosh (intrauterine growth restriction): a systematic review

Concept of fetal well-being has gained importance in conventional science in recent era, but this concept of ‘supraja janana’ was a prime concern of Ayurveda since old era. Apart from prematurity, intrauterine growth restriction (IUGR) is a major public health problem in most of the developing countries. While going through ayurved classics it is revealed that garbhashosh is one of the disease, which is comparable to intrauterine growth restriction in modern medicine. In Ayurveda various drugs and preparations have been described for treatment of garbhashosh. These drugs are comparatively safe without any unwanted side effects. Aim of this work was to review and meta-analyze the effictiveness of various ayurvedic treatment modalities for garbhashosh with respect to (w.r.t.) IUGR. An attempt to expand the concept of IUGR according to Ayurveda and to yield a flourishing result to this world-wide problem through Ayurveda, this topic has been selected for the study. Going through pathology and main clinical signs and symptoms, garbhashosh can be correlated with IUGR. It is observed that, total 5 clinical studies and 1 case study have been reported on management of IUGR by using classical formulations of Ayurveda. The results and observations obtained through demographical data, effect of therapy observed on the ultrasound parameters as well clinical parameters of garbhashosh w.r.t. IUGR were statistically significant. Results were obtained in favour of most of the ayurvedic formulations. Through this review it can be stated that bruhaniya gana sidha kshirbasti and kshirpan, shatavari kshirbasti, shatavaryadi kshirbasti, yashtimadhu vidari siddha kshirbasti, shatavari ashwagandha phalaghruta kshirbasti, can be given to a pregnant women with IUGR after completion of 28th weeks of gestation, without any complication either in mother or in child. It is cost effective as compared to modern drug.

Indication for Doppler evaluation in the management of intrauterine growth restriction of vascular origin in Sub-Saharan Africa

Objective: To assess the contribution of Doppler in foetal monitoring and decision-making during delivery in case of in-utero vascular growth retardation.
 Design: We conducted a retrospective cohort study from January 2015 to December 2017 in the Gynaecology and Obstetrics Department of the Yopougon University Hospital (Abidjan, Ivory Coast). It included 130 patients who gave birth in a setting of pre-eclampsia with intrauterine growth restriction (IUGR) from 28 weeks of amenorrhoea.
 Results: The average age of patients was 31years. Nulliparous (33% of our patients) and pauciparous (41% of our patients) women were the group most affected. The mean gestational age at the first Doppler examination was 32 weeks of amenorrhoea. Doppler abnormalities were 65% in uterine Doppler and 90% in umbilical Doppler. The meancerebrovascular ratio was reversed in 90% of the cases. Perinatal mortality was 22.3% (n = 29) with 21 foetal death in utero and 8 neonatal deaths. The time interval between absent end-diastolic or reverse flow velocity and in-utero foetal death was 3.8 days.
 Conclusion: Foetal and umbilical Doppler ultrasound greatly modified the management of intrauterine growth retardation related to hypertension.

Indication for Doppler evaluation in the management of intrauterine growth restriction of vascular origin in Sub-Saharan Africa

Objective: To assess the contribution of Doppler in foetal monitoring and decision-making during delivery in case of in-utero vascular growth retardation.
 Design: We conducted a retrospective cohort study from January 2015 to December 2017 in the Gynaecology and Obstetrics Department of the Yopougon University Hospital (Abidjan, Ivory Coast). It included 130 patients who gave birth in a setting of pre-eclampsia with intrauterine growth restriction (IUGR) from 28 weeks of amenorrhoea.
 Results: The average age of patients was 31years. Nulliparous (33% of our patients) and pauciparous (41% of our patients) women were the group most affected. The mean gestational age at the first Doppler examination was 32 weeks of amenorrhoea. Doppler abnormalities were 65% in uterine Doppler and 90% in umbilical Doppler. The meancerebrovascular ratio was reversed in 90% of the cases. Perinatal mortality was 22.3% (n = 29) with 21 foetal death in utero and 8 neonatal deaths. The time interval between absent end-diastolic or reverse flow velocity and in-utero foetal death was 3.8 days.
 Conclusion: Foetal and umbilical Doppler ultrasound greatly modified the management of intrauterine growth retardation related to hypertension.

Placental elasticity assessment by point shear wave elastography in pregnancies with intrauterine growth restriction

Background Placental elasticity varies in different diseases. Our objective was to evaluate placental elasticity using point shear wave elastography (pSWE) in pregnancies with intrauterine growth restriction (IUGR). Methods A total of 66 pregnant women with IUGR and 81 healthy pregnant women were enrolled. Placental elasticity was measured using the transabdominal pSWE method. Ten measurements were made, and the mean was accepted as the mean placental elasticity value in each case. The results for IUGR pregnancies and controls were compared. Results The mean pSWE values were significantly higher in pregnancies with IUGR, which means that women with IUGR have stiffer placentas (P < 0.001). Furthermore, the pSWE values were significantly and positively correlated with Doppler indices and adverse perinatal outcomes. Conclusion The pregnancies with IUGR had stiffer placentas than the healthy controls. The utilization of pSWE for placental elasticity may be useful in the diagnosis and management of IUGR as a supplement to the existing ultrasonography methods.

Multidisciplinary consensus on screening for, diagnosis and management of fetal growth restriction in the Netherlands

BackgroundScreening for, diagnosis and management of intrauterine growth restriction (IUGR) is often performed in multidisciplinary collaboration. However, variation in screening methods, diagnosis and management of IUGR may lead to confusion. In the Netherlands two monodisciplinary guidelines on IUGR do not fully align. To facilitate effective collaboration between different professionals in perinatal care, we undertook a Delphi study with uniform recommendations as our primary result, focusing on issues that are not aligned or for which specifications are lacking in the current guidelines.MethodsWe conducted a Delphi study in three rounds. A purposively sampled selection of 56 panellists participated: 27 representing midwife-led care and 29 obstetrician-led care. Consensus was defined as agreement between the professional groups on the same answer and among at least 70% of the panellists within groups.ResultsPer round 51 or 52 (91% - 93%) panellists responded. This has led to consensus on 27 issues, leading to four consensus based recommendations on screening for IUGR in midwife-led care and eight consensus based recommendations on diagnosis and eight on management in obstetrician-led care. The multidisciplinary project group decided on four additional recommendations as no consensus was reached by the panel. No recommendations could be made about induction of labour versus expectant monitoring, nor about the choice for a primary caesarean section.ConclusionsWe reached consensus on recommendations for care for IUGR within a multidisciplinary panel. These will be implemented in a study on the effectiveness and cost-effectiveness of routine third trimester ultrasound for monitoring fetal growth. Research is needed to evaluate the effects of implementation of these recommendations on perinatal outcomes.Trial registrationNTR4367.

Relationship between Doppler findings and fetal brain apparent diffusion coefficient in early-onset intra-uterine growth restriction

Objective: The aim of the study is to assess the relationship between uteroplacental Doppler sonography findings and cerebral diffusion measured by diffusion-weighted magnetic resonance imaging (DWI) in fetuses with early-onset intrauterine growth restriction (IUGR).Materials and methods: The study included 54 pregnant women with fetal IUGR and 15 healthy controls (n: 15). Fetuses with IUGR were classified into four groups based on Doppler findings: group 1 (n = 12), umbilical artery (UA) pulsatility index (PI) > 95pc; group 2 (n = 11), UA PI >95 pc and middle cerebral artery PI < 5pc; group 3 (n = 21), absent end-diastolic (A-EDF) in UA; group 4 (n = 10), reversed EDF in UA. After Doppler evaluation, DWI was performed in all patients within hours. The groups were compared with respect to apparent diffusion coefficient (ADC) levels.Findings: In cases with fetal IUGR, significant decreases were detected in ADC values of periatrial white matter (PAWM) (p = .01), frontal white matter (FWM) (p = .038), thalamus (p = .004), and basal ganglia (p = .013) compared to controls. In Doppler subgroup analysis adjusted for gestational age, ADC values of FWM, thalami, and pons were significantly lower in group 4 than control group (p = .02, p = .02, and p = .037, respectively). In PAWM, ADC values were significantly lower in group 4 than control and Group 1 (p = .004). No significant differences with regard to ADC values in basal ganglia, cerebellum was found between Doppler groups and control.Conclusions: In fetuses with IUGR, ADC values as measured by DWI decreases. The critical Doppler finding that is associated with reduced diffusion in some brain areas (FWM, PAWM, thalami, pons) is reverse end-diastolic flow in umbilical artery. Further prospective studies with larger sample size are needed to introduce cerebral ADC values in the management of IUGR

Cardiotocography and the evolution into computerised cardiotocography in the management of intrauterine growth restriction.

Timely recognition and appropriate management of high-risk pregnancies, such as intrauterine growth restriction (IUGR), are of paramount importance for every obstetrician. After the initial screening of IUGR fetuses through sonographic fetometry and Doppler, the focus is shifted to the appropriate monitoring and timing of delivery. This can, especially in cases of early IUGR, become a very difficult task. At this point, cardiotocography (CTG) is introduced as a major tool in the day-to-day monitoring of the antenatal well-being of the IUGR fetus. Since the first introduction of CTG up to the nowadays widely spreading implementation of computerised CTG in the clinical practice, there has been great progress in the recording of the fetal heart rate, as well as its interpretation. Focus of this review is to offer an understanding of the evolution of CTG from its early development to modern computerised methods and to provide an insight as to where the future of CTG is leading, especially in the monitoring of IUGR.

Management of intrauterine growth restriction

Intrauterine growth restriction (IUGR) is a condition where the fetus does not attain its biologically determined growth potential due to a pathological process. The main tools for antenatal surveillance in a growth-restricted fetus include amniotic fluid volume, Doppler studies, and biophysical profile. The frequency of surveillance depends on the severity of the growth restriction and the findings on previous ultrasound studies. The decision to deliver the fetus is dependent on factors such as gestational age, severity of growth restriction, and findings on the Doppler studies. If there is severe abnormality in the Doppler studies, lower segment cesarean section is recommended as the mode of delivery. Vaginal delivery may be attempted after induction of labor if Doppler parameters are normal, in a center with adequate facilities for monitoring facilities and when there are personnel with expertise. This review provides an overview of antenatal monitoring in a pregnancy with IUGR and decision-making during the time of delivery.

A new aproach of intrauterine growth restriction

Intrauterine growth restriction is defined as the fetal failure of achieving the endorsed growth potential and the diagnosis is made on the basis of ultrasound estimated fetal weight below the 10th centile in the absence of a gold standard for defining this condition. Fetuses with growth restriction are at risk for perinatal morbidity and mortality and for poor long-term health outcomes. In the last 10 years many algorithms have been developed aiming to prevent these consequences. This year new consensus-based definitions for early and late fetal growth restriction, including cut-off values for parameters, have been agreed. An update in diagnosis and management of intrauterine growth restriction, through a review of the latest publications in the field, presents the arguments for decisions necessary to produce national guidelines and recommendations of clinical practice in order to reduce the perinatal morbidity and mortality due to this condition, whose prevalence is estimated at 6-7% of total births in Romania.

Maternal Administration of Sildenafil Citrate Alters Fetal and Placental Growth and Fetal-Placental Vascular Resistance in the Growth-Restricted Ovine Fetus.

Intrauterine growth restriction (IUGR) causes short- and long-term morbidity. Reduced placental perfusion is an important pathogenic component of IUGR; substances that enhance vasodilation in the uterine circulation, such as sildenafil citrate (sildenafil), may improve placental blood flow and fetal growth. This study aimed to examine the effects of sildenafil in the growth-restricted ovine fetus. Ewes carrying singleton pregnancies underwent insertion of vascular catheters, and then, they were randomized to receive uterine artery embolization (IUGR) or to a control group. Ewes in the IUGR group received a daily infusion of sildenafil (IUGR+SC; n=10) or vehicle (IUGR+V; n=8) for 21 days. The control group received no treatment (n=9). Umbilical artery blood flow was measured using Doppler ultrasound and the resistive index (RI) calculated. Fetal weight, biometry, and placental weight were obtained at postmortem after treatment completion. Umbilical artery RI in IUGR+V fell less than in controls; the RI of IUGR+SC was intermediate to that of the other 2 groups (mean±SEM for control versus IUGR+V versus IUGR+SC: ∆RI, 0.09±0.03 versus -0.01±0.02 versus 0.03±0.02; F(2, 22)=4.21; P=0.03). Compared with controls, lamb and placental weights were reduced in IUGR+V but not in IUGR+SC (control versus IUGR+V versus IUGR+SC: fetal weight, 4381±247 versus 3447±235 versus 3687±129 g; F(2, 24)=5.49; P=0.01 and placental weight: 559.7±35.0 versus 376.2±32.5 versus 475.2±42.5 g; F(2, 24)=4.64; P=0.01). Sildenafil may be a useful adjunct in the management of IUGR. An increase in placental weight and fall in fetal-placental resistance suggests that changes to growth are at least partly mediated by changes to placental growth rather than alterations in placental efficiency.

Diagnosis and Management of IUGR in Pregnancy Complicated by Type 1 Diabetes Mellitus.

This review discusses available literature on the diagnosis and management of intrauterine growth restriction (IUGR) in women with type 1 diabetes. IUGR is diagnosed when ultrasound-estimated fetal weight is below the 10th percentile for gestational age. IUGR diagnosis implies a pathologic process behind low fetal weight. IUGR in pregnancy complicated by type 1 diabetes is usually caused by placental dysfunction related to maternal vasculopathy. Prevention of IUGR should ideally start before pregnancy. Strict glycemic control and intensive treatment of nephropathy and hypertension are essential. Low-dose aspirin initiated before 16 gestational weeks can also reduce IUGR risk in women with vasculopathy. Umbilical and uterine artery Doppler studies can guide diagnosis and surveillance of fetuses with IUGR. Decisions regarding the timing of delivery should be based on assessment of umbilical artery Doppler. The risk of prematurity and impaired fetal lung maturation should always be considered, especially in fetuses younger than 32 weeks.

Restricción del crecimiento intrauterino: una aproximación al diagnóstico, seguimiento y manejo

SUMMARY Background: Intrauterine growth restriction has a multifactorial origin and can be caused by a variety of pathologies in the mother, fetus or placenta, representing high rates of maternal and perinatal morbidity and mortality. Therefore, it is important to accurately diagnose this condition in order to focus in the follow and management, which can reduce the complications associated with the disease. Objective: To perform a detailed and up to date review of the etiology, diagnostic criteria, follow up with Doppler ultrasonography and management of intrauterine growth restriction. Methods: A literature search was done in English and Spanish in databases such us PubMed/MEDLINE, Ovid, MDconsult using the following key words: intrauterine growth restriction, small for gestational age fetus, fetal circulation, Doppler ultrasonography. Also national statistics for intrauterine growth restriction were used, obtaining 61 documents. The information obtained

To Doppler or not to Doppler

This review aims to provide the reader with an update on the present and potential clinical applications in Doppler ultrasound in perinatal medicine. Umbilical artery Doppler plays an important role in the management of intrauterine growth restriction (IUGR) and preeclampsia and aids in twin-to-twin transfusion syndrome management while notching in the waveform is a predictor of umbilical cord abnormalities. Middle cerebral artery Doppler reliably detects fetal anemia and may be useful in the assessment of IUGR as well. Abnormal uterine artery Doppler may play a role in predicting growth restriction, hypertensive disorders of pregnancy and preterm delivery. Abnormal ductus venosus waveforms can also be used to predict adverse fetal outcome and may allow for better timing of delivery while umbilical venous pulsations may be a sensitive marker for fetal heart failure in hydropic pregnancies. 3D power Doppler allows better small vessel visualization that is not affected by angle of insonation and has been used to diagnose placental and cord abnormalities. Significant improvements have recently occurred, improving the visualization and evaluation of placental vascularity, resulting from enhancements in delineation of tissue detail through electronic compounding and harmonics, as well as enhancements in signal processing of frequency- and/ or amplitude-based color Doppler ultrasound. Spatial representation of vascularity can be improved by utilizing 3D processing. Greater sensitivity of 3D Doppler ultrasound to macro- and microvascular flow has provided improved anatomic and physiologic assessment throughout pregnancy. The rapid development of these new ultrasound techniques will continue to enlarge the scope of clinical applications in placental studies. As clinical experience with these new technologies increase and as the technology improves further, it is reasonable to expect that 3D Doppler and 4D ultrasound will be complementary addition to well established 2D Doppler ultrasound imaging.

P13.19: Management of intrauterine growth restriction of placental origin before 32 weeks of gestation: a French national survey of current practices

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Effect of l-Arginine on Nitric Oxide Levels in Intrauterine Growth Restriction and its Correlation with Fetal Outcome.

The current management of intrauterine growth restriction (IUGR) being empirical and aimed at selecting a safe time for delivery. Acknowledging the beneficial effects of l-arginine on endothelial vasculature the present study was designed to evaluate efficacy of l-arginine on bioavailability of nitric oxide (NO) with respect to fetal outcome. With l-arginine supplementation, mean NO levels were significantly increased and a significant mild reduction in systolic/end-diastolic velocity ratio (S/D ratio) was observed on doppler blood flow study, also neonatal outcome improved and incidences of complications were lowered. A deficiency in NO may play an important role in the causation of asymmetric fetal growth restriction. l-Arginine can be used to increase maternal NO levels, enhancing birth weight and decreasing neonatal morbidity. The ideal candidate for arginine therapy according to our study would be IUGR cases with S/D ratio less than 4.96±0.49 and NO levels below 33μmol/L with minimum of 3weeks duration of arginine supplementation.

Cerebral blood flow studies in the diagnosis and management of intrauterine growth restriction

To provide evidence that fetal brain vasodilatation can be related with postnatal cerebral structural and functional complications. Most early-onset intrauterine growth restricted (IUGR) fetuses show signs of brain vasodilatation. As most of them are born prematurely, a high prevalence of short-term and long-term neurological complications is expected. However, the clinical significance of brain vasodilatation might be different. In the early stage of fetal deterioration, the risk of structural brain damage is low, but at advanced stages there is an increased risk of periventricular leukomalacia and intraventricular hemorrhage. The presence of brain vasodilatation in fetuses with an estimated fetal weight below the 10th centile but normal umbilical artery Doppler can be used to identify late-onset IUGR fetuses with latent placental insufficiency. These fetuses have an increased risk of abnormal neurological performance at birth and at 2 years of age. Changes in cerebral brain blood perfusion in IUGR fetuses can be detected by Doppler ultrasound techniques. Despite its association with structural and functional neurological damage after birth, fetal brain vasodilatation is usually not considered in the decision to deliver, with the only exception of the 'return' to normal middle cerebral artery pulsatility index, which is highly associated with an increased risk for perinatal mortality.