IUGR

The CCRMC OBGYN Dept and the East Bay Perinatal Consultants should be utilized liberally for management plans. Plans and the source should be documented in the Problem list in order to minimize confusion. The goal of management of suspected fetal growth restriction is intervening in order to improve outcome for the few babies that are suffering from uteroplacental insufficiency without causing iatrogenic prematurity in the larger number that are constitutionally small, actually younger, or inaccurately measured by ultrasound.
 * Is This Baby Too Small??? **

The first step in determining if there is a possible growth restricted fetus is to establish the estimated gestational age (EGA). See "Establishing the Due Date." It is essential that you verify the gestational age being used to calculate the growth percentile on an ultrasound report.
 * Estimate Gestational Age **

Fundal Heights and Risk Factors

 * =====Usually growth concern occurs after 30-32 weeks gestation.If the fundal height (FH) is 3 cm or more less than the gestational age then consider whether there is possible growth restriction--normally an urgent limited OB ultrasound for growth assessment is ordered. =====
 * =====If this occurs before 30 weeks and is mild without risk factors and there is normal fetal movement, ordering an ultrasound and following closely (weekly) should be adequate.If the FH is dramatically different (>4 cm less) with good dates—please consult. =====
 * =====If the size measures less than dates by 3 cm or more after 30-31 weeks then schedule biweekly monitoring (NST/AFI) and order a formal ultrasound for growth. If the estimated gestational weight is < 10% an umbilical artery Doppler measurement is recommended and should be automatically performed by the our radiology department. =====


 *  How Concerned Should I Be? **

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You should be more concerned if she has risk factors such as hypertension, prior preeclampsia, smoking, methamphetamine use or h/o an intrauterine fetal demise and less concerned if she has no risk factors and some explanation such as maternal size is small, or a history of small healthy babies. =====

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Once you get the fetal growth ultrasound result then interpret it using the Hadlock chart below. We have agreed to use Hadlock, again to improve consistency, as there is no chart that specifically addresses our patient population.This chart should be similar to percentages given by radiology (the ultrasound software percentages are based on the Hadlock numbers) if they are using the same gestational age. =====

Hadlock Fetal Growth Chart
On-line calculator. []

Estimated fetal wt in grams
 * weeks || 3rd percent || 10th percent || 50th percent ||
 * 25 || 589 || 652 || 785 ||
 * 26 || 685 || 758 || 913 ||
 * 27 || 791 || 876 || 1055 ||
 * 28 || 908 || 1004 || 1210 ||
 * 29 || 1034 || 1145 || 1379 ||
 * 30 || 1169 || 1294 || 1559 ||
 * 31 || 1313 || 1453 || 1751 ||
 * 32 || 1465 || 1621 || 1953 ||
 * 33 || 1622 || 1794 || 2162 ||
 * 34 || 1783 || 1973 || 2377 ||
 * 35 || 1946 || 2154 || 2595 ||
 * 36 || 2110 || 2335 || 2813 ||
 * 37 || 2271 || 2513 || 3028 ||
 * 38 || 2427 || 2686 || 3236 ||
 * 39 || 2576 || 2851 || 3435 ||
 * 40 || 2714 || 3004 || 3619 ||

 Management for possible growth restricted fetuses will vary some depending on risk factors, maternal stature, certainty of dates etc.In general, fetuses less than 10th percentile are considered concerning for IUGR. Assuming no other indication for monitoring, we have agreed to monitor with biweekly NST/amniotic fluid assessment those fetuses less than the 15th percentile and those pending ultrasound evaluation.

Please understand that their will be different opinions on when to deliver but in general we have agreed to the following scheme:

Management
EFW 10-15% by ultrasound: Continue to monitor fundal height. If risk factors or small fetal size inconsistent with maternal size, continue or start biweekly NST/AFI. No indication to induce prior to 41 weeks if monitoring reassuring and >10th percentile. Follow up growth sonos at 3 week interval should be considered.

EFW < 10% by ultrasound: Biweekly NST/amniotic fluid assessment in antepartum testing clinic. Once weekly umbilical artery dopplers. Q 3 week limited ultrasound for fetal growth. Induce labor at 39 weeks EGA if monitoring reassuring and fetus continues to grow.

If NST or amniotic fluid not reassuring in antepartum testing she will be referred to labor and delivery for further assessment and possible delivery. If umbilical artery Doppler has absent or reverse flow labor __immediately__ send to L and D for delivery or transfer to ABMC if < 34 weeks for inhouse monitoring and decision about delivery timing

More severe growth restriction,e.g. < 3-5%, increasing or asymmetric growth (AC smaller than other measurements), the presence of risk factors, no or minimal fetal growth between q 3 week ultrasounds, or umbilical Doppler measurement approaching 1 (absent diastolic flow) are reasons to consider delivery at 37-39 weeks gestation. Consult an OB Attending for a plan and document plan and source in Problem list.

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