Intrauterine Growth Restriction (IUGR)

Know why she is being delivered - Umbilical artery Doppler drives the timing: absent end-diastolic velocity delivers at 34 weeks or later, reversed end-diastolic velocity at 32 weeks or later. An abnormal cardiotocography tracing or biophysical profile is what turns a plan into a cesarean. IUGR by itself is not an indication for cesarean.

Uteroplacental perfusion is the whole game - There is no reserve left. Treat spinal hypotension immediately with phenylephrine or ephedrine rather than watching a trend, and keep left uterine displacement from 20 weeks on — through transfer, positioning, and any resuscitation.

Fetal bradycardia in the room - In utero fetal bradycardia means fetal compromise. Work the list: aortocaval compression, maternal hypotension, maternal hypoxemia or anemia, cord compression, uterine contraction, placental separation. Increase maternal inspired oxygen, restore blood pressure with vasoactive drugs and fluid, and reposition.

Expect a magnesium infusion - Magnesium sulfate is given for neuroprotection when very preterm delivery under 32 weeks is anticipated. It prolongs the effect of nondepolarizing muscle relaxants and raises the risk of uterine atony and hemorrhage. Loss of patellar reflexes is the bedside sign of hypermagnesemia; calcium gluconate antagonizes magnesium at the neuromuscular junction.

Antenatal corticosteroids - Given up to 34 weeks for fetal lung maturation, so a preterm IUGR delivery usually arrives already steroid-loaded.

Find the maternal driver - IUGR rarely travels alone. Blood pressure trend, urine protein, platelet count, and creatinine sort out preeclampsia and chronic hypertension; the history flags systemic lupus erythematosus, antiphospholipid syndrome, sickle cell disease, severe anemia, significant cardiopulmonary or renal disease, and substance use. The coexisting disease, not the growth restriction, usually decides your anesthetic.

Have the neonatal team and a warm room - The IUGR newborn is set up for perinatal asphyxia, meconium aspiration, respiratory distress, hypoglycemia, polycythemia with hyperviscosity, hypocalcemia, hyperbilirubinemia, sepsis, and poor thermoregulation. Warmer and glucose ready before delivery.

Plan for a preterm neonate - Spontaneous preterm labor is about three times more likely than with a normally grown fetus and perinatal death risk is five- to sixfold higher, so add the prematurity list: respiratory distress syndrome, necrotizing enterocolitis, patent ductus arteriosus, intracranial hemorrhage, retinopathy of prematurity.

She is still a full stomach - Aspiration prophylaxis before a cesarean regardless of technique: sodium citrate 30 mL PO, famotidine 20 mg IV or pantoprazole 40 mg IV, and metoclopramide 10 mg IV.

Intrauterine growth restriction (IUGR), also called fetal growth restriction, is an estimated fetal weight below the 10th percentile for gestational age — a fetus that has failed to reach its genetic growth potential, as distinct from one that is constitutionally small. It complicates about 3% to 7% of pregnancies.

Roughly 70% to 80% are asymmetric, from a late second- or third-trimester insult that is usually placental: failed uterine artery remodeling, placental vascular sclerosis and infarction cut oxygen and nutrient delivery, and the fetus redistributes blood preferentially to brain, heart, adrenals, and placenta while abdominal circumference falls off. The remainder are symmetric, from early insults — aneuploidy, TORCH infection, chronic hypertension, smoking, cocaine. Either way the placental reserve is already spent, so any further fall in uteroplacental perfusion is poorly tolerated.