Intra Uterine Growth Restriction - SASUOGsasuog.org.za/subsiteTeachings/Presentations/2010...

Intra Uterine Growth Restriction

Laurent J SALOMO�

Laurent J SALOMONMaternité Necker-IPP

Paris

• What is it ?

• What to look for ?• What to look for ?

• How to manage IUGR ?

Laurent J SALOMO�

Recent studies

Normal growth of the fetal biparietal diameter and the abdominal diameter in a longitudinal study. An evaluation of the two parameters in predicting fetal weight.

Longitudinal studies of fetal growth using volume parameters determined with ultrasound.

Eriksen PS, Secher NJ, Weis-Bentzon M. Acta Obstet Gynecol Scand. 1985;64(1):65-70.

Laurent J SALOMO�

Longitudinal studies of fetal growth using volume parameters determined with ultrasound.

Ultrasonic patterns of intrauterine fetal growth in a Latin American country.

Ultrasound assessment of fetal growth patterns.

Diagnosis of the small-for-dates fetus by serial ultrasonic cephalometry

Deter RL, Harrist RB, Hadlock FP, Cortissoz CM, Batten GW. J Clin Ultrasound. 1984 Jul-Aug;12(6):313-24.

Campbell S, Dewhurst CJ. Lancet. 1971:Nov;2(7732):1002-6.

Meire HB. Br Med Bull. 1981 Sep;37(3):253-8.

Fescina RH, Ucieda FJ, Cordano MC, Nieto F, Tenzer SM, Lopez R. Early Hum Dev. 1982 Jul;6(3):239-48.

Be careful….

• Different concepts:

– fetal size

– fetal growth

– Related morbidity/mortality

Laurent J SALOMO�

Fetal biometry:

To identify fetuses at high risk of perinatal

mortality and morbidity with a reliable and

reproducible tool.

Laurent J SALOMO�

Most oftern, we use fetal

biometry as a screening

test for IUGR….

• Among term infants with BW<3rd centile Increased risk of :

• Neonatal mortality

• Low Apgar.

Why should we care about IUGR ?

• Low Apgar.

• Ph<7

• Intubation

• Seizure and sepsis.

McIntire D. New England Journal Med 99

Ob/Gyn professional

activity:

• For 300 deliveries.year par an:

– 1 DS every 3 years?

– 1 CHD every 3 years?

– 1 myelomeningocele every….?– 1 myelomeningocele every….?

– 1 mitochondrial cytopathy every…..

– Everyday life: preterm, IUGR, infection….,

• Cut-off choice

Laurent J SALOMO�

Let’s talk biometry

• MoM

• Percentile

• Z-score

Laurent J SALOMO�

• Expected value

• Variability around that value

1.2 MoM 1.2 MoM

Laurent J SALOMO�

Centile:

75th centile

50 75 955 25

Laurent J SALOMO�

5 25 50 75 95

SD et Z score…:

SD

-1.96 +1.96

9597.5

Laurent J SALOMO�

M

M

50

-1.96 +1.962.5% 2.5%

-1.645 +1.6455% 5%

52.5

Z score = 0

Z score= 1.645

Z score=1.96

Z score= -1.645

Fetal size:

• Biometry:

– BPD, HC

– AC

– FL

• Strict rules:

Laurent J SALOMO�

• Strict rules:

– GA

– Quality control of measurements

• Cross sectional or longitudinal approach.

• Symmetrical plane

• Plane showing

the thalami

• Plane showing the cavum septi pellucidi

• Cerebellum not visible

Laurent J SALOMO�

• Cerebellum not visible

• Head plane occupying more than half of the total image size

• Callipers and dotted ellipse correctly placed

• Symmetrical plane

• Plane showing the stomach

bubble

• Plane showing the portal sinus

• Kidneys not visible

• Abdominal plane occupying more

Laurent J SALOMO�

• Abdominal plane occupying more

than half of the total image size

• Callipers and dotted ellipse

correctly placed

• Both ends of the bone

clearly visible

• < 45° angle with the

horizontal line

• Femoral plane

Laurent J SALOMO�

• Femoral plane

occupying more than

half of the total image

size

• Callipers correctly

placed

Biometry

Laurent J SALOMO�

ANXIETY

FRUSTRATION

OK

PRIDE

ANXIETY

ANXIETY

ANXIETY

OK

• Appropriate reference

Laurent J SALOMO�

• Appropriate measurements…..

PERFECT !

GTT for every

woman !

Karyotype !

Laurent J SALOMO�5th 95th

Karyotype !

Wonderful life !

Bad day !

BPD

65

75

85

95

105

BP

D

BPDn95

BPDpnicolaides

BPDn5

BPDpChitty95

Laurent J SALOMO�

15

25

35

45

55

65

12 14 16 18 20 22 24 26 28 30 32 34 36 38 40 42

AG

BP

D

BPDpChitty

BPDChitty5

BPDpKurma95

BPDpKurma

BPDKurma5

Laurent J SALOMO�

Z score =0.04 Z score=-0.42 Z score=-0.9

Laurent J SALOMO�

Quality Control

Laurent J SALOMO�

Practically

• Look at the article

• See the reference plane

• Think

• Compare

• Evaluate

Laurent J SALOMO�

Biometric Measurements: Screening

Value for IUGR

1

AC

AD

HC

FL

0

0,1

0,2

0,3

0,4

0,5

0,6

0,7

0,8

0,9

1

0 0,2 0,4 0,6 0,8 1

THURNAU

PA

SHEPARD 1

ROSE 1

HADLOCK 2

DEPISTAGE DE L'HYPOTROPHIE DANS UNE POPULATION A BAS RISQUE

ENTRE 37 ET 39 SA

DEPISTAGE DE L'HYPOTROPHIE DANS UNE POPULATION A BAS RISQUE

ENTRE 37 ET 39 SA

Abdominal Circumference

Estimated Fetal Weight

THURNAU

AC

SHEPARD 1

ROSE 1

HADLOCK 2

Using a 10% cut-off:

-Will identify half of newborns

actually weighing < 10th centile

-Will identify most of newborns

who will suffer from IUGR

related problems

Estimated Fetal Weight

The ideal Formula is the one that best suits

your practice !

But also

Little bias < 1%Little bias < 1%

High level of precision < 5% CCCCC.

log EFW = 1.326 + 0.0107 HC + 0.0438 AC + 0.158 FL – 0.00326 AC x FL

Hadlock AJOG 1985

95% limits of agreement ranged from −4.4%

to +3.3% for inter- and intraobserver

estimates,

but were −18.0% to 24.0% for estimated and

actual birth weight.

There was no improvement in accuracy

between 1991 and 2000.

In 2000 only six of the 12 published formulae In 2000 only six of the 12 published formulae

had overall bias within 7% and precision

within 15%.

There was greater bias and poorer precision

in nearly all equations if the birth weight was

<1000 g.

REPRODUCIBLE

But Inaccurate

Especially < 1000 g C

•Clinical estimate has an accuracy similar to that of ultrasound

at term

•Ultrasound is superior to clinical estimate before 37 weeks’

INACURRACY: Technical Factors

Chauhan AJOG 1998

80% of EFW are within 10% of the actual birthweight

The remainders are within 20% of the actual BW

Normal RangeNormal Range

EFW / HadlockN = 18,958

Normal Range

BirweightN = 58,934

BW charts reflect a significant proportion of premature growth retarded neonate

Reporting EFW on BW charts is therefore misleading

At 28-32 weks’ the 50th centile for BW is the 10th centile for EFW !

Interval between US examination

and false positive rate on EFW [5% Variation on AC]

28 SA 26,6% 1,2%4,2%11,8%

1st US examination 1 Wk 2 Wks 3 Wks 4 Wks

Interval

30 SA

32 SA

34 SA

36 SA

29,2%

30,8%

33,3%

34,4%

2,0%6,4%14,1%

3,2%8,1%16,9%

5,1%10,3%19,4%

6,9%12,7%22,1%

1st US examination

Mongelli 1998

• The main issue is not to identify small babies.

Laurent J SALOMO�

• The main issue is not to identify small babies.

It is to identify those « at risk »

Longitudinal:

• Calculate growth velocities.

• Fetus is its own control (≠ transversal

approach).

• Express as mm/w or g/w or conditional • Express as mm/w or g/w or conditional

approach

• Growth anomaly associated with

perinatal morbidity (Smith-Bindman

2002 Radiology).

The Longitudinal Approach:

ex. conditional

Cross-Sectional Charts: All fetuses must comply with GA

Longitudinal Growth Charts: The Fetus is its own Control.

Fetus A: EFW 1090 @ 28w and 1730 @ 32w

Fetus B :EFW 1250 @ 28wand 1730 @ 32 w 3rd centile

Owen P. UOG 2000

and 1730 @ 32w 50th centile

Laurent J SALOMO�

Customised Growth

Charts

Accounts for maternal and fetal physiological variables: MW @

booking, M Height, Ethnic group, Parity & Fetal gender.

28% Babies < 10th centile would be « normal »

24% AGA Babies would be <10th centile

• Mrs A

• 160 cm, 58 Kg

• chinese

• nulliparous

• Baby girl 38 w

• 2900 g

Gardosi, Lancet 1992

66th centile

• Mrs B

• 175 cm, 85 Kg

• Swedish

• 2P

• Baby boy 38 w

• 2900 g

7th centile

• Better screening (Clausson BJOG 2001)

• Lower FPR (Gardosi BJOG 2000)

• 10th centile cut-off (de Jong Ultrasound

2000)

Laurent J SALOMO�

2000)

Impact of 3D Ultrasound ?

Fetal Fat Mass: 12 – 14% of FW

But explains 46% of its variance !Catalano 1992

Fetal overall volumetry

Leads to significant overestimationChang 1997

Lee et al UOG 2006

FRACTIONAL VOLUMETRY

Screening conclusion…

• Screening test.

• Quality control, appropriate GA.

Laurent J SALOMO�

• Quality control, appropriate GA.

• Appropriate references.

• Use of EFW but Se ~50%

• Customised growth charts, longitudinal

approach, 3D....

• Use other indicators:

– Maternal history.

– Clinical examination

– AFI, Doppler...

Laurent J SALOMO�

– AFI, Doppler...

• What is it ?

• What to look for ?

• How to manage IUGR ?

Laurent J SALOMO�

Trisomy 18 Trisomy 18

Ultrasound Ultrasound

FindingsFindings •• Esophageal atresia Esophageal atresia

•• ExomphalosExomphalos

•• Renal defectsRenal defects

•• MyelomeningoceleMyelomeningocele

•• Short limbsShort limbs

•• StrawberryStrawberry--shaped shaped

headhead

•• Choroid plexus cystsChoroid plexus cysts

•• Absent corpus Absent corpus

callosumcallosum •• Short limbsShort limbs

•• Radial aplasia/hypoplasiaRadial aplasia/hypoplasia

•• Overlapping fingersOverlapping fingers

•• Talipes or rocker bottom Talipes or rocker bottom

feetfeet

callosumcallosum

•• VentriculomegalyVentriculomegaly

•• DandyDandy--Walker Walker

complexcomplex

•• Facial cleftFacial cleft

•• MicrognathiaMicrognathia

•• Cardiac defects Cardiac defects

•• Diaphragmatic hernia Diaphragmatic hernia

••Holoprocencephaly Holoprocencephaly

Anophthalmia/microphthalAnophthalmia/microphthal

miamia

Trisomy 13 Trisomy 13

Ultrasound Ultrasound

FindingsFindings

•• Partial molePartial mole

•• Growth restrictionGrowth restriction

•• Mild ventriculomegalyMild ventriculomegaly

Triploidy Triploidy

Ultrasound FindingsUltrasound Findings

miamia

•• Abnormal noseAbnormal nose

•• Facial cleftsFacial clefts

•• Cardiac abnormalitiesCardiac abnormalities

•• OmphaloceleOmphalocele

•• Renal abnormalitiesRenal abnormalities

•• Postaxial polydactylyPostaxial polydactyly

•• MyelomeningoceleMyelomeningocele

•• Mild ventriculomegalyMild ventriculomegaly

•• MicrognathiaMicrognathia

•• Cardiac abnormalitiesCardiac abnormalities

•• OmphaloceleOmphalocele

•• Small abdomenSmall abdomen

•• MyelomeningoceleMyelomeningocele

•• 3rd3rd--4th fingers syndactyly4th fingers syndactyly

•• “Hitch“Hitch--hiker” toe deformityhiker” toe deformity

OTHER CHROMOSOMAL OTHER CHROMOSOMAL

DEFECTSDEFECTS

4p 4p -- deletiondeletion

NON CHROMOSOMAL DEFECTSNON CHROMOSOMAL DEFECTS

Smith Lemli Opitz Syndrome Smith Lemli Opitz Syndrome

OsteochondrodysplasiasOsteochondrodysplasias

Other Recessive ConditionsOther Recessive Conditions

Placentitis, Hyperechogenic bowel, Hepatosplenomegaly, myocarditis, Califications

Anemia, Thrombocytopenia, Liver enzymes & GGTP

RCIURCIU

• What is it ?

• What to look for ?

• How to manage IUGR ?

Laurent J SALOMO�

1. Fetal well being at US

2. Cardiotocography

3. STV3. STV

4. Doppler

5. MRIA.

Fetal Wellbeing

Biophysical Profil: Manning / Vintzileos

STV= 7.4

Short Term Variability

• Objective

• Quantitative

• Longitudinal

Normal Variability

STV= 2.9

(Dawes & Dawes & RedmanRedman criteriacriteria))

Decreased Variability

EFFECT OF CORTICOSTEROIDS EFFECT OF CORTICOSTEROIDS

ON CTGON CTG

Decreased VariabilityDecreased Variability

Loss of AccelerationsLoss of AccelerationsLoss of AccelerationsLoss of Accelerations

••24 to 72 hours24 to 72 hours

••More marked with betamethasoneMore marked with betamethasone

••Venous Doppler UnchangedVenous Doppler Unchanged

DVDVUmbilical A.

Ductus Venosus

Mid cerebral A.

DVDV

IVCIVC

AOAO

Umbilical A.

Aortic Isthmus

Artères à destinée brachio-céphalique

Ventricule

droit

Ventricule

Gauche

Isthme aortique

Tronc de l’artère

pulmonaire

Artère pulmonaire droite

Artère pulmonaire gauche

Flux provenant du

ventricule droit traversant

le canal artériel

Aorte ascendante

Artère pulmonaire

droite

Aorte descendante

Veine cave

Coronaires

droit

Placenta

Veine

ombilicale

Veine cave

inférieure

suprahépatique

Veine cave inférieure

préhépatique

Ductus venosusSang peu saturé en O2Sang saturé en O2

Artère

ombilicale

Reins

Tube digestif

Veine

hépatique

droite

Veine hépatique gauche

Foie

Umbilical Artery: PI, EDF ++++

Doppler Measurement at the level of the fetal bladder

Perinatal Mortality 75/4 512

(1,66 %)

123/4 602

(2,67 %)

0,64

[0,47 ; 0,86] *

Criterias

(13 trials)

Doppler

nb (%)

Control

nb (%)

odds ratio[interv conf 95 %]

The use of umbilical Doppler

is asociated with a 40% decrease in

perinatal mortality

PNM

Excl. malformations 57/4 512

(1,26 %)

97/4 602

(2,11 %)

0,62

[0,45 ; 0,86] *

IUFD

Excl. malformations 23/4 512

(0,51 %)

45/4 602

(0,98 %)

0,54

[0,29 ; 0,91] *

Neonatal Mortality

Excl. malformations34/4 512

(0,75 %)

52/4 602

(1,13 %)

0,68

[0,40 ; 1,05]

Goffinet et al

ReferencesReferences for MCAfor MCA

Laurent J SALOMON

SS

dd

V SystoleV Systole

aa

EarlyEarly diastolediastole

Late diastoleLate diastole

All hepatic veins are not the

DV..

DVDV

IVCIVC

AOAO

> 600 g

> 26 weeks’

Median (95% CI) survival (%) for European infants known to be alive at onset of labour

Draper et al. 1999

Longitudinal Study of IUGR

(London, Hamburg, Amsterdam, Utrecht)

Longitudinal Study of IUGR

(London, Hamburg, Amsterdam, Utrecht)

• 93 fetuses

• 3-27 examinations (mean:5)

• 93 fetuses

• 3-27 examinations (mean:5)• 3-27 examinations (mean:5)

• 1-83 days before Delivery

• 3-27 examinations (mean:5)

• 1-83 days before Delivery

Hecher et al, 2002Hecher et al, 2002

Gestational Age at Delivery Gestational Age at Delivery

and PNMand PNM

Gestational Age at Delivery Gestational Age at Delivery

and PNMand PNM

< 32 wks: n = 60; PNM n = 16 (27%)< 32 wks: n = 60; PNM n = 16 (27%)< 32 wks: n = 60; PNM n = 16 (27%)< 32 wks: n = 60; PNM n = 16 (27%)< 32 wks: n = 60; PNM n = 16 (27%)< 32 wks: n = 60; PNM n = 16 (27%)

> 32 wks: n = 33; PNM n = 1 (3%)> 32 wks: n = 33; PNM n = 1 (3%)

Total: n = 93; PNM n = 17 (18%)Total: n = 93; PNM n = 17 (18%)

< 32 wks: n = 60; PNM n = 16 (27%)< 32 wks: n = 60; PNM n = 16 (27%)

> 32 wks: n = 33; PNM n = 1 (3%)> 32 wks: n = 33; PNM n = 1 (3%)

Total: n = 93; PNM n = 17 (18%)Total: n = 93; PNM n = 17 (18%)

Delivery before 32 wks

Days before Del

Progression of Anomalies

•• AmnioticAmniotic fluidfluid

•• OA PiOA Pi

•• MCA PiMCA Pi•• MCA PiMCA Pi

•• AortaAorta PiPi

•• STVSTV

•• IVC PiIVC Pi

•• DuctusDuctus VenosusVenosus

Doppler in 224 severe IUGR

CTG Biophysical

Profile Doppler

MANAGEMENTMANAGEMENT

•Umbilical Artery Doppler as the primary surveillance tool•Use Biophysical Profile & Cardiotocography infrequently•AFI & Deepest pool have similar accuracy

•When EDF is present, delay delivery until at least 28 wks

•When EDF is absent or reversed, admission and steroidsDeliver if any other parameter is abnormal (BPP, CTG, Venous Doppler) or maternal

Preeclampsia Preeclampsia

• Elective delivery from 34 weeks

•Use Gestation-Birthweight specific charts from 24 weeks’•Administer Steroids below 36 weeks

•Deliver in an appropriate Unit•Intrapartum monitoring with Continuous CTG

RCOG guidelines 2003

GA > 26 W , EFW > 600 gGA > 26 W , EFW > 600 g

Doppler 1Doppler 1--2 / week2 / week

Elective delivery before Elective delivery before

32 sa32 sa

Absent / reversed EDF in the umbilical artery

Positive EDF in the umbilical artery

Admit , CorticosteroidsAdmit , Corticosteroids

DV AbnormalDV Abnormal

STV NormalSTV Normal

DV AbnormalDV Abnormal

STV < 3 msSTV < 3 ms

CTG & Doppler 1x/ dayCTG & Doppler 1x/ day

DV NormalDV Normal

STV NormalSTV Normal

DV NormalDV Normal

STV < 3 ms STV < 3 ms DELIVERYDELIVERY