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Intrauterine growth restriction - symmetrical

Case contributed by Fabien Ho

Presentation

Past history of pre-eclampsia.

Patient Data

Age: 25 years
Gender: Female

21 weeks gestation

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 occurring in early 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 monitor properly:

  • maternal consequences on blood pressure and related CNS, kidney and liver disorders

  • fetal demise with intrauterine fetal death

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