Hello Mr. XXXXXXX again,
Hearing from a patient again is never trouble!

Well, first let me give you normal fetal growth parameters at 32 weeks
BPD ( Biparietal diameter - measures size of fetal head - across it ) - 81 + / - (4.0) mm
HC ( Head circumference - another measure of fetal head - around it ) 288 + / - ( 25 ) mm
AC ( abdominal circumference - measures around the stomach or abdomen of baby ) - 283 +/- (30) mm
FL ( femur length - measures lower limbs of baby ) - 62 + / - (6.0) mm
Estimated fetal weight - 10th Percentile is 1621 gms. and 90th percentile is 2285 gms.

These are international charts, and each baby's growth is determined to a great extent by the parental genes, What I want to say is that small parents tend to have smaller children. Also, estimation of these parameters by ultrasound is often subjective ( inter observer variation can be upto 10 % ) and even when a single observer repeats the ultrasound, errors of upto 10 % are observed, so it is better to act on the clinical judgement of the obstetrician rather than just ultrasound reports.

That said, two aspects of the ultrasound are not normal. First is obviously, the fetal weight which is less than the 10th percentile, and the AC, which is also less than normal. Hence, your baby by definition is having IUGR ( intra uterine growth restriction ). The most common definition of intrauterine growth restriction (IUGR) is a fetal weight that is below the 10th percentile for gestational age as determined through an ultrasound.

IUGR affects 3-10% of pregnancies. 20% of stillborn infants have IUGR. Perinatal mortality rates are 4-8 times higher for infants with IUGR, and morbidity is present in 50% of surviving infants. Whether it will improve or not depends on the cause for IUGR.

There are basically two different types of IUGR:

Symmetric or primary IUGR is characterized by all XXXXXXX organs being reduced in size. Symmetric IUGR accounts for 20% to 25% of all cases of IUGR.
Asymmetric or secondary IUGR is characterized by the head and brain being normal in size, but the abdomen is smaller. Typically this is not evident until the third trimester. This is the problem you are facing, as the AC is less than the head and limb parameters.

Pregnancies that have any of the following conditions may be at a greater risk for developing IUGR:

An underweight or obese mother
Poor nutrition during pregnancy
Birth defects or chromosomal abnormalities in the baby
Use of drugs, cigarettes, and/or alcohol
Pregnancy induced hypertension (PIH)
Placental abnormalities
Umbilical cord abnormalities
Multiple pregnancy
Gestational diabetes in the mother
Low levels of amniotic fluid or oligohydramnios

Firstly, your doctor should screen your wife for any of these conditions.

One of the most important things when diagnosing IUGR is to ensure accurate dating of the pregnancy. Gestational age can be calculated by using the first day of your last menstrual period (LMP) and also by early ultrasound calculations.

Once gestational age has been established, the following methods can be used to diagnose IUGR:

Fundal height that does not coincide with gestational age - clinical examination by your gynecologist.
Measurements calculated in an ultrasound are smaller than would be expected for the gestational age
Abnormal findings discovered by a Doppler ultrasound ( Doppler ultrasound assesses the blood supply to the baby, because obviously when the baby is not growing normally, somewhere the blood supply is compromised )


Despite lots of research the optimal treatment for IUGR remains problematic. Most likely the treatment will depend on how far along you are in your pregnancy.

If gestational age is 34 weeks or greater, health care providers may recommend being induced for an early delivery.
If gestational age is less than 34 weeks, health care providers will continue monitoring until 34 weeks or beyond. Fetal well-being and the amount of amniotic fluid will be monitored during this time. Serial ultrasound and Colour Doppler will be done, and if either of these becomes a concern, then immediate delivery may be recommended, even if preterm. You have not mentioned the amniotic fluid levels in your ultrasound, and also whether a Colour Doppler was done or not. Also, your wife was given Injection Betnesol ( steroid shot ) at 32 weeks, to enhance the lung maturity of the baby, because normally, full lung maturity is attained only after 37 weeks.

The risks to your baby if born with IUGR :

Increased risk for cesarean delivery
Increased risk for hypoxia (lack of oxygen when the baby is born)
Increased risk for meconium aspiration, which is when the baby swallows part of the first bowel movement. This can cause the alveoli to be over distended, a pneumothorax to occur, and/or the baby can develop bacterial pneumonia.
Hypoglycemia (low blood sugar)
Polycythemia (increased number of red blood cells)
Hyperviscosity (decreased blood flow due to an increased number of red blood cells)
Increased risk for motor and neurological disabilities

Intravenous fluids and protein and amino acid drip has been given in your case to improve the nutrition to the baby. However, it does not guarantee improvement.
Basic pointers for you now :

1. Urgent amniotic fluid assessment and Colour Doppler.
2. If both are normal, serial antenatal check up and ultrasound with Doppler every week to see for improvement.
3. If these remain within tolerable ranges, pregnancy can be continued till 37 weeks, after which an elective Cesarean delivery can be planned.
4. If there is deterioration in any of these parameters, then preterm delivery maybe required.
5. Proper bedrest, sleep always in the left lateral position ( improves blood supply to the baby ), take lots of fluids ( atleast 4 - 5 litres per day in form of water, nimbu pani, buttermilk, soups, juices- home made not processed ), nutritious diet ( 2 eggs per day, protein powder, XXXXXXX leafy vegetables ), Supplements like LR Zin XXXXXXX one or two sachets daily.
6. Strict attention to daily fetal movements - after breakfast, lunch and dinner, ask your wife to lie in the left lateral position for one hour each. The total of the three hours should be atleast 10 movements. If less than this, to urgently see your doctor.
7. Lastly stay positive and stress free ( I know its difficult ! ) because maternal stress will compound effects of IUGR.

In this day and age, modern scientific advances will surely ensure you a healthy baby, as your wife has already crossed 32 weeks.

Take care, and feel free to ask me any further questions.

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Hi XXXXXXX

Argipreg sachets have same composition as LR zin sachets, and she should try to have one atleast daily, even two will help.
You can also take Nourish protein powder 2 tablespoons twice a day in a glass of milk and two Threptin biscuits everyday ( protein supplements)
As I said, two eggs daily.
If she is a non vegetarian, daily helpings of chicken ( grilled ) and fish would help.
She should increase her intake of daal, dry fruits, nuts etc.
A lot of fluids are a must - keep a one litre bottle ready for measurement and ensure she has atleast 4 - 5 such bottles a day.
Stay in touch with your gynec, and yes, avoid stressing out your wife.
Make sure she gets atleast 8 hours of night time sleep and 2 hours of daytime nap ( in left lateral position as advised ).
Do keep me posted - its always a pleasure.
take care, and wish you well.

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