Intrauterine growth restriction - symmetrical

Case contributed by Dr Fabien Ho

Presentation

Past history of pre-eclampsia.

Patient Data

Age: 25 years
Gender: Male

US at 21WG

Ultrasound

Severe IUGR with an estimated fetal weight barely reaching 239g at 21WG (usually approx 500g is expected at this term). All biometric parameters < 3rd percentile.
Pathological umbilical Doppler with reversed diastolic flow.
Middle cerebral artery Doppler remained normal, indicating a relative vasodilation to preserve brain from damage: vascular redistribution, with a cerebro-placental ratio < 1, RI MCA / RI umbilical <1.
Ductus venosus Doppler : A wave is flat, which reflects increased filling pressure in the right atrium.
Bilateral uterine Dopplers showed protodiastolic notch (not shown), which is a non relevant finding at this stage with obvious abnormal umbilical Doppler. 
Placenta had a round shape with poor basal surface area and echoic aspect.  

Case Discussion

Typical findings of a vascular IUGR, which occurred early in pregnancy, with already severe findings. In theory, US anomalies occur in the following order : Uterine notches -> asymmetrical IUGR -> umbilical Doppler with high RI -> fetal redistribution to preserve brain -> brain growth not preserved: symmetrical IUGR -> reverse diastolic flow in umbilical cord -> tricuspid insufficiency then elevated right atrium pressure: flat A wave on ductus -> cardiac failure -> intrauterine death. 

Identification of such situations is critical to properly monitor:

  • maternal consequences on blood pressure and related CNS, kidney and liver disorders
  • fetal demise with Intrauterine fetal death

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