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<10th Percentile EFW
(+ Abnormal Doppler)
2–4 wks Monitoring Interval
(Mild–Moderate IUGR)
2 Types Early-Onset (<32 wks)
Late-Onset (≥32 wks)
5–10% Pregnancies Affected
(Leading Cause of Stillbirth)
What is IUGR?

Not Just a Small Baby —
A Placenta That Cannot Keep Up

Fetal Growth Restriction (FGR), also known as Intrauterine Growth Restriction (IUGR), is a condition in which the baby is unable to achieve its expected growth potential in the womb — because the placenta is not delivering adequate nutrition and oxygen.

A baby with estimated fetal weight below the 10th percentile for gestational age is classified as small for gestational age (SGA). When this smallness is combined with evidence of placental dysfunction on Doppler — elevated umbilical artery resistance, brain-sparing on MCA Doppler, or reduced amniotic fluid — the diagnosis is IUGR. The distinction matters profoundly: a constitutionally small baby with a healthy placenta is not at risk. An IUGR baby with a failing placenta needs careful, expert surveillance and precisely timed delivery.

IUGR is one of the leading causes of stillbirth, perinatal death, and long-term disability — and most of these outcomes are preventable with expert monitoring and the right delivery decision. At Mayflower Fetal Medicine Centre, Dr. Kunda Shahane provides comprehensive IUGR surveillance using the GE Voluson Signature Expert.

IUGR — At a Glance
Definition: EFW < 10th percentile + evidence of placental insufficiency on Doppler
Root cause: Placental dysfunction — inadequate oxygen and nutrient delivery
Key test: Umbilical artery Doppler + MCA Doppler + ductus venosus
Monitoring: Serial growth scans every 2–4 weeks; Doppler at each visit
Decision tool: Doppler findings determine when delivery must be planned
Prevention: Low-dose aspirin from <16 weeks in high-risk patients
Risk: Leading cause of stillbirth — largely preventable with correct surveillance
The Most Important Distinction: Small Baby vs IUGR

This is the first question Dr. Kunda Shahane answers at every referral for a small baby — because the management is completely different.

✓ Constitutionally Small Baby

  • Placenta functioning normally
  • Doppler: umbilical artery normal
  • Growth velocity: consistent along centile
  • Amniotic fluid: normal
  • MCA Doppler: normal
  • Management: reassurance + standard monitoring

⚠ True IUGR — Placental Failure

  • Placenta not delivering adequately
  • Doppler: elevated umbilical artery resistance
  • Growth velocity: falling across centiles
  • Amniotic fluid: often reduced (oligohydramnios)
  • MCA Doppler: brain-sparing (low resistance)
  • Management: intensive surveillance + delivery planning
Types of IUGR

Early-Onset vs Late-Onset —
Two Very Different Clinical Scenarios

The gestational age at which IUGR develops profoundly affects its severity, its associated risks, and how it is managed. Dr. Kunda Shahane tailors the surveillance protocol to each type.

Before 32 Weeks
Early-Onset IUGR

The most severe form. Early-onset IUGR arises from profound placental dysfunction — most often associated with hypertension, pre-eclampsia, autoimmune disease, or thrombophilia. The placenta begins to fail early in pregnancy, when the baby is still very preterm.

Doppler abnormalities develop rapidly and progress through a predictable sequence — from elevated umbilical artery resistance to absent then reversed end-diastolic flow, with ductus venosus abnormality as the final pre-terminal sign. The baby may have very little reserve.

Management requires weekly — sometimes twice-weekly — Doppler monitoring, hospital admission when Doppler deteriorates, antenatal corticosteroids for lung maturity, and delivery as soon as the risk of remaining in the womb outweighs the risks of prematurity.

Often co-exists with pre-eclampsia · Requires most intensive monitoring
From 32 Weeks Onwards
Late-Onset IUGR

The more common form. Late-onset IUGR arises from gradual placental insufficiency — often related to maternal hypertension, gestational diabetes, advancing placental age, or with no identified cause. The placenta was functioning adequately earlier but is now falling behind.

Doppler may be normal or show only mild abnormalities initially. The key early marker is brain-sparing on MCA Doppler — a low MCA pulsatility index, indicating the baby is already redirecting blood flow to protect the brain. Growth deceleration across centiles on serial scans is the other hallmark.

Management involves growth scans every 2–3 weeks, regular Doppler checks, and delivery planning — usually at 37–38 weeks for mild cases, earlier if Doppler worsens or the baby stops growing.

More common · Brain-sparing is the key early Doppler finding
Why IUGR Happens

Causes of Fetal Growth Restriction

Understanding why a baby has IUGR guides monitoring intensity, informs recurrence risk counselling for future pregnancies, and identifies any treatable contributing factors.

Placental Insufficiency

The most common cause by far. The placenta fails to grow, invade the uterine wall adequately, or function at the level the growing baby requires. Visible as elevated umbilical artery Doppler resistance. Often the final common pathway regardless of the underlying maternal condition.

Most Common
Hypertension and Pre-Eclampsia

Elevated maternal blood pressure — whether pre-existing or gestational — restricts blood supply to the placenta. Pre-eclampsia is particularly associated with early-onset IUGR and is the single most important risk factor for severe early growth restriction.

Major Risk Factor
Diabetes with Vascular Disease

Long-standing diabetes with vascular complications reduces placental blood flow — paradoxically causing growth restriction in the same condition more commonly associated with large babies. Gestational diabetes rarely causes IUGR unless complicated by hypertension.

Pre-Existing Diabetes
Autoimmune Conditions

Systemic lupus erythematosus (SLE), antiphospholipid syndrome, and other autoimmune conditions promote placental thrombosis and inflammation — significantly increasing IUGR risk. Women with these conditions require early, intensive Doppler surveillance at Mayflower Clinic.

High-Risk Group
Chromosomal Conditions

Severe IUGR — especially when combined with structural anomalies — may be caused by a chromosomal abnormality such as Trisomy 18 (Edwards syndrome) or Trisomy 13. Genetic testing may be recommended when no placental cause is identified in early-onset severe IUGR.

Consider in Severe/Early IUGR
Fetal Infections

Congenital infections — particularly cytomegalovirus (CMV), rubella, and toxoplasma — can affect both placental function and direct fetal growth. TORCH infection screen is part of the investigation workup for unexplained early-onset IUGR.

Less Common
💊
Prevention: Low-Dose Aspirin Before 16 Weeks

In women identified as high risk for pre-eclampsia and IUGR at the first trimester scan — through abnormal uterine artery Doppler, maternal risk factors, or combined screening — low-dose aspirin (150 mg at night) started before 16 weeks has been proven to reduce the risk of early-onset pre-eclampsia and severe IUGR by over 60%.

This is one of the most important preventive interventions in fetal medicine. Dr. Kunda Shahane discusses aspirin prophylaxis with every high-risk patient at the first trimester screening appointment. If you have not been assessed for your pre-eclampsia risk this pregnancy, speak to us.

The Doppler Escalation Ladder

How Doppler Guides Every Decision
From Surveillance to Safe Delivery

A growth scan can tell you a baby is small. Only Doppler can tell you why — and how urgently action is needed. In IUGR, Doppler findings follow a predictable escalation pathway. Dr. Kunda Shahane interprets each step and acts accordingly.

Each rung represents a more severe level of placental compromise — and a more urgent clinical response. The progression is not always linear: some babies deteriorate slowly over weeks; others can drop rapidly in days.
✅ Stage 1
Reassuring
Normal Doppler — Small Baby, Healthy Placenta
EFW < 10th percentile · Umbilical artery Doppler normal · MCA normal · AFI normal. Baby is constitutionally small or mildly small for gestational age, but the placenta is coping well.
→ Growth scan + Doppler every 2–4 weeks. Delivery at term or per obstetric indication. Reassurance appropriate.
⚠️ Stage 2
Early Warning
Elevated Umbilical Artery PI + / or Brain-Sparing
Umbilical artery resistance rising (elevated PI/RI) and/or MCA pulsatility index reduced (brain-sparing). Placenta is struggling — baby is beginning to redistribute blood to protect the brain and heart.
→ Growth scan + full Doppler every 1–2 weeks. Biophysical profile if MCA brain-sparing confirmed. Delivery planning discussion initiated.
🔶 Stage 3
Significant
Absent End-Diastolic Flow (AEDF)
Blood flow in the umbilical artery completely stops during the diastolic phase of the cardiac cycle. This means placental resistance is so high that the baby's heart cannot push blood through it between beats. A critical finding.
→ Hospital admission if <34 weeks. Antenatal steroids for lung maturity. CTG + ductus venosus Doppler daily. Delivery if ≥34 weeks or if other markers deteriorate.
🔴 Stage 4
Urgent
Reversed End-Diastolic Flow (REDF)
Blood flow in the umbilical artery is literally pushed backwards — away from the placenta — between heartbeats. This indicates catastrophic placental resistance. The baby is in severe haemodynamic compromise. Fetal reserves are critically depleted.
→ Hospital admission. Delivery must be planned within days. Ductus venosus Doppler guides the exact timing. Near-continuous CTG monitoring. Neonatology team alerted.
🆘 Stage 5
Emergency
Abnormal Ductus Venosus — Cardiac Decompensation Imminent
Absent or reversed A-wave in the ductus venosus signifies that fetal cardiac function is failing under the pressure of severe placental insufficiency. This is the pre-terminal Doppler finding — fetal death is imminent without intervention.
→ IMMEDIATE delivery — within hours. Emergency caesarean section at any viable gestational age. Every hour counts.
Dr. Kunda Shahane interprets every Doppler in full clinical context — gestational age, biophysical profile, CTG findings, maternal condition, and growth trajectory. The Doppler stage is one input in a nuanced clinical decision, not an automatic trigger. No two IUGR pregnancies are managed identically.
At Every Monitoring Visit

What Dr. Kunda Shahane Evaluates Each Visit

Each IUGR monitoring appointment at Mayflower Clinic is a complete assessment — not a single measurement. Six parameters are reviewed together to build the full picture of fetal wellbeing.

Estimated Fetal Weight (EFW) & Centile Trend

Biometry of head, abdomen, and femur used to calculate EFW, which is plotted on a growth chart. The critical information is not the single measurement but the trend across serial scans — is the baby growing along its centile, or falling across centiles?

Umbilical Artery Doppler

Measurement of blood flow resistance from baby to placenta. The pulsatility index (PI), end-diastolic flow presence/absence/reversal — this is the primary indicator of placental function and the main driver of management decisions in IUGR.

MCA Doppler — Brain-Sparing

Middle cerebral artery peak systolic velocity and pulsatility index. A low MCA PI (brain-sparing) confirms haemodynamic redistribution — the baby is protecting its brain. This is an early and sensitive sign of fetal compromise in late-onset IUGR.

Ductus Venosus Doppler

Added when umbilical artery AEDF/REDF is present or when the clinical picture is deteriorating. Abnormal ductus venosus (absent or reversed A-wave) signals cardiac decompensation and is the most critical pre-terminal finding — requiring immediate delivery.

Amniotic Fluid Index (AFI)

Reduced amniotic fluid (oligohydramnios — AFI <5 cm) accompanies IUGR when the baby redirects blood away from the kidneys, reducing urine output. Severe oligohydramnios alongside abnormal Doppler significantly increases the urgency of delivery planning.

Biophysical Profile (BPP)

A combined assessment scoring fetal breathing movements, body movements, tone, and amniotic fluid — each scored 0 or 2. Total score out of 10 (sometimes combined with CTG for modified BPP). Used as an acute marker of fetal wellbeing when Doppler findings are abnormal.

Monitoring Protocol

IUGR Surveillance Schedule at Mayflower Clinic

The frequency of monitoring depends on the severity of IUGR and the Doppler findings at each visit. Dr. Kunda Shahane provides each patient with a personalised schedule.

IUGR Severity & Doppler Monitoring Frequency What is Checked When to Deliver
SGA + Normal Doppler
Routine		 Growth scan + Doppler every 2–4 weeks EFW centile trend, UA Doppler, AFI At term (37–40 weeks) unless Doppler changes
Elevated UA PI + Brain-Sparing MCA
Intensified		 Growth + Doppler every 1–2 weeks; CTG if <34 weeks EFW, UA Doppler, MCA, AFI, CTG, BPP if indicated 37 weeks (or earlier if Doppler worsens)
Absent End-Diastolic Flow (AEDF)
Urgent		 Doppler + CTG every 1–3 days; hospital if <34 weeks UA, MCA, ductus venosus Doppler; daily CTG; BPP 34 weeks if stable; earlier if ductus venosus abnormal
Reversed End-Diastolic Flow (REDF)
Very Urgent		 Daily monitoring in hospital; continuous CTG Ductus venosus daily; CTG continuous; neonatology consultation Within days — gestational age dependent
Abnormal Ductus Venosus
Emergency		 Immediate delivery planning Emergency caesarean section preparation IMMEDIATE — within hours
The Hardest Decision

When Is the Right Time to Deliver?

Delivery timing in IUGR is the central clinical decision — balancing the risk of remaining in a failing placental environment against the risks of prematurity. Too late risks stillbirth; too early risks prematurity. Dr. Kunda Shahane makes this decision using all available data.

37–38 wks
Mild IUGR, Normal Doppler
Baby is growing slowly but the placenta is still functioning. Delivery is planned at 37–38 weeks before the placenta begins to fail further. No need for very early delivery.
34–37 wks
Abnormal Doppler, Stable
Placenta functioning below capacity but the baby is compensating. Delivery is planned at 34–37 weeks depending on severity. Antenatal steroids given if <34 weeks to mature baby's lungs.
30–34 wks
AEDF / REDF on Doppler
The baby can no longer safely remain in the womb. Delivery must occur at 30–34 weeks after corticosteroids for lung maturity. Hospital admission is mandatory. The exact timing is guided by ductus venosus Doppler.
Immediate
Abnormal Ductus Venosus
Cardiac decompensation is imminent. Delivery is an emergency regardless of gestational age. Every hour of delay increases the risk of stillbirth. Emergency caesarean section is performed immediately.
Important: These are general guidelines — every IUGR pregnancy is different. Dr. Kunda Shahane will discuss the specific timing recommendation for your pregnancy, taking into account gestational age, all Doppler parameters, biophysical profile, maternal condition, and the availability of neonatal care.
What to Bring

Preparing for Your IUGR Monitoring Appointment

✓ IUGR Monitoring Appointment Checklist

  • ✓All previous growth scan reports: Growth scans from previous visits — even from other centres — are essential for plotting the growth trend. EFW centile over time is more informative than any single measurement.
  • ✓Previous Doppler reports: Any prior Doppler scans (umbilical artery, MCA, uterine artery) should be brought. Dr. Kunda Shahane will review the trend across visits to assess whether findings are stable or deteriorating.
  • ✓Referral letter or obstetrician notes: If you have been referred from another obstetrician, bring the referral letter and all clinical notes. The reason for referral and the clinical context matter significantly.
  • ✓Blood pressure readings: A record of recent blood pressure measurements (from home monitor or clinic) is valuable, particularly if hypertension or pre-eclampsia is a concern.
  • ✓Partially full bladder: Drink 2–3 glasses of water 30–45 minutes before the appointment. Good hydration improves ultrasound imaging and amniotic fluid assessment.
  • ✓Blood tests if ordered: If your obstetrician has ordered investigations (full blood count, liver function, uric acid, 24-hour urine for pre-eclampsia), bring the reports if available.
  • ✓Your questions written down: IUGR monitoring visits cover a lot of information. Writing your questions down in advance helps ensure nothing is overlooked.
  • ✓Bring your partner if possible: Two pairs of ears are always better than one when making important clinical decisions. Having your partner or a family member present is encouraged.
Watch Dr. Kunda Shahane
Fetal Medicine and High-Risk Pregnancy — Dr. Kunda Shahane, Mayflower Clinic Nagpur
Frequently Asked Questions

Your IUGR Questions, Answered

My baby is small on the growth scan — does that mean it has IUGR?
Not necessarily. A baby measuring below the 10th percentile is called small for gestational age (SGA) — but SGA has two very different causes. A constitutionally small baby is small because of genetics (the parents are small) but has a healthy, functioning placenta — normal Doppler, normal amniotic fluid, and consistent growth along its centile. True IUGR is when smallness is combined with placental dysfunction — evidenced by abnormal umbilical artery Doppler, brain-sparing on MCA Doppler, or reduced amniotic fluid. The first step at Mayflower Clinic is always to make this distinction, because the management is completely different.
What exactly does the Doppler scan measure in IUGR?
Doppler measures blood flow velocities in the blood vessels connecting the baby to the placenta — and within the baby itself. The umbilical artery measures how hard the baby's heart works to push blood through the placenta. As the placenta fails and resistance rises, blood flow in diastole diminishes, eventually becomes absent (AEDF), and then reverses (REDF) — each step representing a more severe degree of compromise. The MCA Doppler detects brain-sparing — the baby redirecting blood to protect the brain. The ductus venosus Doppler, nearest to the heart, detects cardiac decompensation. Together, these three Doppler parameters give Dr. Kunda Shahane a complete picture of where the baby sits on the IUGR escalation ladder.
Is there any treatment for IUGR?
Once IUGR is established, there is no treatment that reverses the underlying placental dysfunction — the management goal is expert surveillance and delivery at the optimal time. For women identified as high risk before IUGR develops, low-dose aspirin started before 16 weeks can significantly reduce the risk of early-onset IUGR. During the monitoring period, women are advised to maintain good hydration, adequate rest, and optimal management of any underlying condition (hypertension, diabetes, lupus). The decision on when to deliver — balancing fetal compromise against prematurity — is the primary clinical intervention.
What is brain-sparing? Is it dangerous?
Brain-sparing is the baby's compensatory response to placental insufficiency — it redirects blood flow away from the gut, kidneys, and skin towards the brain and heart to maintain oxygen supply to vital organs. On MCA Doppler, it appears as a reduced pulsatility index (low resistance) in the middle cerebral artery. Brain-sparing is a sign that the baby is aware of the compromise and actively compensating — it is not an emergency in itself, but it tells us that fetal reserves are being used. It is an important escalation marker that increases monitoring frequency and initiates delivery planning. In late-onset IUGR particularly, brain-sparing often precedes more serious Doppler deterioration.
My baby has IUGR — will I need a caesarean section?
Not necessarily. The mode of delivery in IUGR depends on the gestational age, the severity of Doppler findings, fetal position, and the overall obstetric situation. Many IUGR babies with mild-to-moderate compromise can be safely delivered vaginally with careful CTG monitoring in labour. However, IUGR babies with severely abnormal Doppler (AEDF/REDF) or those requiring very preterm delivery (<32 weeks) often need caesarean section because they have very little reserve to tolerate the stress of labour. Dr. Kunda Shahane will discuss the likely mode of delivery at each visit as the pregnancy progresses, so you can plan ahead.
Will my baby be normal after IUGR?
The outcome for babies with IUGR depends greatly on the timing and severity of the growth restriction. Mild late-onset IUGR detected and managed appropriately has an excellent prognosis — most babies catch up in growth within the first 1–2 years of life. Severe early-onset IUGR requiring very preterm delivery carries the risks of prematurity alongside growth restriction — neonatal intensive care is likely needed. Long-term health consequences depend on the degree of prematurity and any perinatal hypoxia. What is most important is that IUGR detected early and managed with expert surveillance gives the baby its best possible chance at every gestational age.
Will IUGR happen in my next pregnancy?
IUGR does have a recurrence risk — particularly when caused by hypertension, pre-eclampsia, or autoimmune conditions. The risk varies depending on the underlying cause and severity. In subsequent pregnancies, high-risk management begins from the first trimester: early uterine artery Doppler, aspirin prophylaxis from before 16 weeks, close surveillance throughout. Dr. Kunda Shahane provides pre-pregnancy and first-trimester counselling for women with a history of IUGR or pre-eclampsia — giving the next pregnancy the best possible start.

Related Services at Mayflower Clinic

Colour Doppler Scan → Growth Scan → High-Risk Pregnancy → First Trimester Screening → Anomaly Scan → Fetal Therapy Procedures → About Dr. Kunda Shahane →

Your Baby's Growth Deserves Expert Eyes.

If you have been told your baby is small, your Doppler is abnormal, or you have risk factors for IUGR — do not wait. Dr. Kunda Shahane provides the most accurate, comprehensive IUGR surveillance in Central India. The right Doppler interpretation today could be the most important thing that happens in your pregnancy.

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Mayflower Fetal Medicine Centre · Dhantoli, Nagpur 440012 · Monday–Saturday 10:00 AM – 6:00 PM

⚖️ PCPNDT Act Compliance Notice Mayflower Fetal Medicine Centre strictly complies with the Pre-Conception and Pre-Natal Diagnostic Techniques (Prohibition of Sex Selection) Act, 1994. Sex determination and sex-selective practices are strictly prohibited and punishable by law. All diagnostic services at this centre are performed exclusively for medical diagnosis and fetal wellbeing. Disclosure of fetal sex is illegal and is not performed at this centre.
Medical Disclaimer: This content is for general information only and does not constitute medical advice. Please consult Dr. Kunda Shahane or your treating obstetrician for advice specific to your pregnancy.