Asymmetrical intrauterine growth restriction with fetal distress

Case contributed by Mostafa Elfeky
Diagnosis almost certain


History of five pregnancies with intrauterine fetal death before 24 weeks of gestation. Presented for Doppler study as the obstetrician observed oligohydramnios.

Patient Data

Age: 35 years
Gender: Female

Oligohydramnios is noted (AFI~4.6 cm), largest pocket 1.8 cm.

While the scan, on applying spectral Doppler over the tricuspid valve area, transient bradycardia occurred for a minute with a heart rate about 60 bpm. Then shifted to tachycardia (190 bpm). Fetal cardiomegaly is noted.

Abnormal umbilical artery Doppler with reversal of diastolic flow.

Normal middle cerebral artery Doppler for gestational age.

The fetus mean gestational age is about 22 weeks, small for gestational age as compared to gestational age by last menstrual period (25 weeks and 3 days), with increased HC:AC ratio and EFW<3rd percentile, suggestive of intrauterine growth restriction - asymmetrical.

The fetus is seen inactive, with periods of absent breath movement. The biophysical profile score was not more than 2/8.

Case Discussion

This case demonstrates many signs of intrauterine growth restriction with fetal distress:

  • abnormal umbilical artery Doppler with reversal of diastolic flow, despite normal middle cerebral artery Doppler, reflecting placental insufficiency
  • fetal bradycardia followed by fetal tachycardia
  • abnormal biophysical profile
  • increased HC:AC ratio
  • associated oligohydramnios 

Unfortunately, the fetus carries a very poor prognosis.

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