asawebinar 1/04/2019 · 2019-04-02 · asawebinar 1/04/2019 7 42 This program is based on fetal weight equation proposed by Hadlock et al. [Hadlock FP, Harrist RB, Martinez-Poyer

asawebinar 1/04/2019

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1

Fetal Diagnosis & Therapy 2014

What is known‐ Growth/ FGR

‐ Differences: Earlier v later

Ultrasound‐ Screening: “at risk”

‐ Management / Intervention

Placental Insufficiency‐ Patholophysiology

‐ Fetal sequalae

Strategies for improvement

Objectives

2

Clinical Concern

Maternal Cause

Maternal size large or small

for dates

Clinical risk factor

Pre-eclampsia

Auto-immune

Clinical Concern

Fetal Cause

Anemia FGRCongenital Anomaly

Placentation/ Fetal

environmentLocation,

Accreta, Percreta

PV bleeding / fluid

Delivery Fetal lie Fibroids, Surveillance

Twin pregnancy

Growth TTTS TAPS

Why do patients present?

Clinical Concern

Maternal Cause

Maternal size large or small

for dates

Clinical risk factor

Pre-eclampsia

Auto-immune

Clinical Concern

Fetal Cause

Anemia FGRCongenital Anomaly

Placentation/ Fetal

environmentLocation,

Accreta, Percreta

PV bleeding / fluid

Delivery Fetal lie Fibroids, Surveillance

Twin pregnancy

Growth TTTS TAPS

Why do patients present?

Fetal Growth Restriction

What is known?

Early OnsetSevere issues placentation Chromosomal abnormalities,

Maternal disease,

Abnormal Ut A/ Umb A

Easier Dx


All FGR - 20-30%

Assoc PE - 50%

All FGR … 70-80%

Assoc PE … 10% !

Figueras 2014

Late OnsetSlower placental insufficiency

Stillbirth

Severe neurodevelopmental

Mild neurodevelopmental

Programming

Normal UA

Complex Dx

What is known?


20-30% 70-80%

LaterStillbirth

Severe neurodevelopmental concerns

Mild neurodevelopmental concerns

Programming

EarlierSignificant implications

Spectrum

Is this a big issue?


2

Stillbirth

‐ Tip of “iceberg”

‐ V common

1.8% all births0.8% perinatal

0.6% fetal

0.4% neonatal

Higher : Indigenous (high risk)

Multifactorial

‐ FGR (placental causes), Pre-eclampsia

What is known...

72009 Aust. Bureau of Statistics

What is known…

8

Births= 92218

SGA= 195/389

Stillbirths= 389

Detected

25/195 (18%)

Not detected

160/195 (82%)

What does this

mean?Not detected SB rate:

19.8: 1000

Detected SB rate: 9.7:

1000

What is known…

9

Births= 92218

SGA= 195/389

Stillbirths= 389

Detected

25/195 (18%)

Not detected

160/195 (82%)

Babies SGA: Higher risk of stillbirth

Not detected SB rate:

19.8: 1000

Detected SB rate:

9.7: 1000

Very poor detection

When detectedDecreased SB rate

Not 2.4:1000

… ? What to do

Inversion pyramid of care (Nicholaides 2003)

T3 Perinatal morbidity/ mortality

‐ Significant issue

‐ T1 PE screening (early only)

Ultrasound monitoring

‐ Fundamental

‐ Problematic

‐ When / Who / Why

What is known...

1929

2014

NIPT MSS NT

Universal 3rd Trimester Screening

Evidence

‐ No significant benefit (Cochrane database 2008)

‐ Minimally better

‐ Fundal height

What is known...

The end game…

Detecting Is this fetus “Growth Restricted”?

(Is this fetus SGA ie. at risk?) (Guide surveillance & intervention)

What is known...


3

The end game…


or failing to meet “growth potential” eg. Gestational Diabetes- Baby on 15th

(Guide surveillance & intervention)

What is known...

13

The end game…


or failing to meet “growth potential”

(Guide surveillance & intervention)

What is known...

14Vast number of clinical strategies

Propose 5 ultrasound focussed strategies

?

?

…. At Monash Quality program: 2013

Why?

1. Improved cervical surveillance

Vasa Previa 20 weeks

…. At Monash Quality program: 2013

Why?

All high risk: EV

Screening-TA imaging‐ Compulsory ID

‐ Int Os, Ext Os, Colour

‐ Lower threshold – EV

‐ Landmarks not seen

‐ Any funnelling

‐ Velamentous cord insert

Auditable: (x2)‐ > 90% compliance

1. Improved cervical surveillance

Vasa Previa 20 weeks


4

SGA – fundamental

Exercise

‐ Good biometry, Recognition poor biometry

‐ Clever decision making (don’t normalise)

2. Understand importance “growth”

3. Clear guidelines scanning /communication

Quality improvement

Quality improvement

Strategy 4. Clear, relevant biometry growth charts

Integration with management pathways

5. And…

Figueros 2014


5

Third Trimester

Focus: US screening for the “fetus at risk

“ The Routine”- Ultrasound Examination

25

“Typical” cascade of Uteroplacental Insufficiency

Growth

Hypoxia

& less

nutrition

Failing placenta

More: Earlier Onset

• Decrease resistance– Cerebral

– Adrenal

– Splenic

– Coronary

Increase resistance

‐ Descending aorta

‐ Renal

‐ Femoral

‐ Pulmonary

‐ Mesenteric

Redistribution During Fetal Hypoxemia

-100

-50

0

50

100

150

200

250

300

Adrenal Heart Brain Placenta Mesenteric Kidney Peripheralvasc

Lung

% change of flow


Growth

Hypoxia

AFI

MCA (PI)

FGRCeased

Growth


Growth

Hypoxia

AFI

MCA (PI)

FGRCeased

Growth

Mild Acidemia

Loss ‘A’

wave

DV

Marked

acidemia

Loss of

breathing/

m’ment


Growth

Hypoxia

AFI

MCA

(PI)

FGRCeased

Growth

Mild Acidemia

Loss ‘A’

wave

DV

Marked

acidemia

Loss of

breathing/

m’ment


6

Baschat 2011

Decompensation

Routine Assessment

Growth

Hypoxia

FGRCeased

Growth

SGA- so important - Obvious

Must be documented

No re-dating

Fetal Growth

http://shansshenanigans.com/tag/giant-baby/

Biometry

‐ BPD, HC, AC, FL

EFW: Derived

‐ Hadlock

EFW = 1.335 − 0.0034 (AC) (FL) + 0.0316(BPD) + 0.0457(AC) + 0.1623(FL)

Centile- Plot on graph

Fetal Growth

SGA – High risk ( <10th ile)

Plotting % ile’s

X

SGA is fetus with EFW <10th%ile (Is an at risk fetus)

FGR- Falling subsequent biometry

‐ > 30% or crossing percentiles.

“A change: Fetal Growth”

SGA

FGR

Which chart?


7

42

This program is based on fetal weight equation proposed by Hadlock et al. [Hadlock FP, Harrist RB, Martinez-Poyer J. In utero analysis of fetal growth: a

sonographic weight standard. /Radiology/ 1991;181(1):129-33.] and adapts the customization proposed by Gardosi et al. [Gardosi J, Chang A, Kalyan B,

Sahota D, Symonds EM. Customised antenatal growth charts. /Lancet/ 1992;339(8788):283-7]. Technical details are described in the Appendix to

Mikolajczyk, Zhang, Betran, Souza, Mori, Gülmezoglu, Merialdi. A Global Reference for Fetal/Birth Weight Percentiles /Lancet/2011. The standard

deviation of birthweight originally presented in the light green field above is derived from the 2004-2008 WHO Global Survey on Maternal and Perinatal

Health.

Nepean, Sydney

Mercy , Melbourne

Routine: Fetal Environment

Growth

Hypoxia

AFI

FGRCeased

Growth

4 quadrant method Chart (Moore et al. 1990)

Single pocket: As good < 2cm vertical depth

Value- questionable (Figueros 2014)

‐ Assoc Apgars 5 min/ Use post dates

Decreased AFI


Umbilical Artery : A placenta test

Growth

Hypoxia

AFI

FGRCeased

Growth

Abnormal relates to:

‐ Perinatal morbidity

‐ Neonatal acidosis (Figueros 2014)

Identifies the “at risk” fetus

Progression

‐ Assists delivery decision

Looking for increased resistance

Abnormal umbilical artery


8

Use chart to plot

‐ 4-5 identical waveforms

Use best SD ratio

Free loop of cord

PI

‐ PI- International

‐ Monitoring very high risk

Umbilical Artery

Sweep speed - No more than 5 pulses

Baseline should be low

‐ Still show reverse flow

Avoid venous overlay

Avoid filters

Optimal Doppler Settings


“Thing that change”

‐ Head, chest, heart, kidneys

Routine: Fetal Anatomy

Is that all for routine assessment?

Routine: Modified Biophysical Profile

V end stage‐ Marked acidemia

Routinely

Modified BPP‐ UA

‐ AFI

‐ Gross movements

‐ Breathing

‐ CTG*

* Done by Obstetricians or mid-wives

Biophysical Profile


9

? Movements/ breathing

Is that all that is done routinely?

Biophysical Profile

• V end stage- Marked acidemia

• Routinely

Formal Biophysical Profile‐ Score out of 10

‐ 0 or 2 (No 1’s)

‐ Movement

‐ Breathing

‐ AFI

‐ Tone

‐ CTG*

* Done by Obstetricians or mid-wives

Biophysical Profile

• Not time based

• SD Ratio of UA

• AFI

• Movement : Gross

• Straightforward

• Breathing

Modified BPP

Plane:

‐ Transverse

‐ Sagittal

Settings

‐ high definition zoom

‐ ↓ dynamic range

‐ ↑ frame rate

How do we test for fetal breathing?

Normal Breathing: Transverse

Normal Breathing: Sagittal

• Diaphragm or Lung movements caused by heart motion

What is not fetal breathing?

Diaphragm LungNot breathing Not breathing

• ? Movements/ breathing

What is not fetal breathing?


10

Cascade of Uteroplacental Insufficiency

Growth

Hypoxia

AFI

MCA (PI)

FGRCeased

Growth

Mild Acidemia

Loss ‘A’

wave

DV

Marked

acidemia

Loss of

breathing/

m’ment

Later Onset (click)


Hypoxia

AFI

MCA (PI)

Mild Acidemia

Loss ‘A’

wave

DV

Marked

acidemia

Loss of

breathing/

m’ment

Later Onset Growth:

Undetected or

Marginal

? Performance of UA

Slower onset

Important: Normal UA

Late Onset FGR

UA in n= 656 SGA FGR

Performance of UA in SGA/ FGR

63

Figueros 2014


Hypoxia

AFI

MCA (PI)

Marked

acidemia

Loss of

breathing/

m’mentMild

Acidemia

Loss ‘A’

wave

DV

Later Onset Growth:

Undetected or

Marginal

The last one…

Management Intervention < 28 weeks

Routine > 28 weeks


11

Later onset: SGA / FGR

O&G 2011

Normal low EDV flow‐ Higher resistive, High PI

‐ No EDV normal

‐ “Too much pressure”

Abnormal low resistive

Rules‐ Still fetus

‐ 0º (PI not angle dependant)

‐ 1cm from origin

‐ Still fetus

Middle Cerebral Artery

Normal low EDV flow

‐ Higher resistive, High PI

‐ No EDV normal

‐ “Too much pressure”

Abnormal low resistive

Rules

‐ Still fetus

‐ 0º (PI not angle dependant)

‐ 1cm from origin

‐ Still fetus

Middle Cerebral Artery

A recap: Is this fetus at risk?

69

Focus: Additional spectral Doppler information to

assist management of the

“at risk fetus”

Ultrasound: Third Trimester

70

Early Onset

‐ Umbilical A

Later Onset

‐ Umbilical A

‐ MCA (>28 weeks)

Spectral Doppler: Screening tool

71


12

Early Onset

‐ Umbilical A

‐ Ductus Venosus

Later Onset

‐ Umbilical A

‐ MCA (>28 weeks)

‐ Aortic Isthmus (>34 weeks)

‐ CPR (>37 weeks)

‐ Uterine A’s (>37 weeks)

Spectral Doppler: Management tool

72

Figueros 2014

At Monash ?

Early Onset

‐ Umbilical A

‐ MCA

‐ Ductus Venosus

Later Onset

‐ Umbilical A

‐ MCA (>28 weeks)


‐ CPR (>34 weeks)


‐ Post Dates – CTG / AFI

Spectral Doppler: Management tool

73

Evidence based: Management guidelines

‐ Know – Local fetal medicine unit uses

Surveillance of the “at risk” fetus

74

Management & Intervention

75

SGA - Early Onset FGR

DuctusVenosus

DV

‐ Narrow cone shaped

‐ <2mm diameter,1-2 cm long

Location

Normal situation

‐ Limits 20% to heart

‐ Rest to liver

‐ Venturi effect

‐ Keeps DV open

Ductus Venosus

Ductus Venosus

ventricular Systole+

atrial relaxation

ventricular Diastole:passive filling

ventricular diastole:Atrial contraction


13

Abnormal

‐ Sign: Fetal hypoxia / Acidemia

Early phase

‐ Redistribution

‐ Dilates – Increased flow

‐ Shunting- more to central circulation

Ductus venosus

Later phase / Marked FGR (early onset)‐ Altered pressure gradient

‐ Coronary vascular bed

‐ Loss – ventricular contractility

‐ Increases cardiac afterload

Reversed A’ wave:

Challenges: ‐ Reversed A wave‐ Predicts fetal demise

‐ Daily: Doubles risk stillbirth

‐ Deliver or not deliver‐ Large trials

Ductus venosus


80

SGA - 34-term weeks

Aortic Isthmus or CPR

Location between‐ PA: Supplies Abdomen/ Limbs

‐ AA: Head/ Neck

DA (Blood from PA) - Functions – shunt‐ Regulatory system

Waveform dependant‐ LVOT

‐ RVOT

‐ Pathophysiological response

Aortic Isthmus

81

Normal waveform‐ Notch: delayed onset & acc time DA

Till 25 weeks > 25 weeks

Aortic Isthmus

82

US OG 2003

Abnormal waveform

‐ Increased shunting- cerebral

‐ Increased peripheral resistance

Abnormal

Aortic Isthmus

83

US OG 2003

Normal


14

Used after 34-37 weeks‐ Predicts neurological morbidity

‐ SGA + Reversed ‐ Cx section (Figueros 2014)

Pre 34 weeks‐ Changes earlier than DV

‐ Limited literature‐ ? Helpful definitive management

After 37 weeks‐ Can be normal in FGR (Figueros 2014)

Difficult !

Aortic Isthmus

84

(Figueros 2014)


85

After 34 weeks

Cerebro-placental Ratios

Born after 34 + weeks

‐ Until well after term

Includes- Outcomes

‐ Stillbirth

‐ Urgent admission to SCN/ NICU

‐ Poor apgars etc

Which babies are we worried about…?

91

Is this fetus “Growth Restricted”?

or

or failing to meet “growth potential”

Cerebro-placental ratio

92MCA UA- Placenta

The case against

Simply

‐ Independent systems

‐ Two markers

‐ Don’t work after 35 weeks

‐ Perception

‐ False positives

Cerebro-Placental Ratio

93

The case for ?

Cerebro-Placental Ratio

94


15

Reproducible, known reference range

Abnormal result reflects worse outcomes

Acting on an abnormal result improves outcomes

What evidence do we need for each Doppler?

CPR - Reproducible, known reference range

96

CPR - Reproducible, known reference range

97

• Associations in SGA• CS for fetal distress

• Lower cord pH

• Higher rate NICU admission

• Perinatal death

• Associations in AGA• CS for fetal distress

• Cord blood acidaemia

• Inc admission to NICU

• Predictor of stillbirth

2015

“CPR is a better predictor than low birthweight for identifying fetuses at risk”

CPR - Abnormal result reflects worse outcomes

98

Routine screening 3rd T?

Admission in labour?

CPR - Acting on an abnormal result improves outcomes

99


100

2016

Births= 473

CPR-Within 1 week of

delivery

“Conclusions: Fetal CPR could be used to identify fetuses at

high risk before labor and to help guide intrapartum

management decisions.”


16


101

2016

Births= 1089

34-37 weeks Gestational

Diabetes (Mater, Brisbane)

“Regardless of the type of treatment, a low CPR was

associated with increased rates of emergency operative birth

and poorer neonatal outcomes in women with gestational

diabetes mellitus..”

V simplistic analysis

102

Maternal anxiety

Possible more

Induction/ c section

Costs

Waste of time

Improved perinatal

Morbidity/ mortalityBeing seen to

do something

Keep up with

The Jones

Early Onset

‐ Umbilical A/ +/- MCA

‐ Ductus Venosus

Later Onset

‐ Umbilical A

‐ MCA (>28 weeks)


‐ CPR (>37 weeks)


Spectral Doppler: And again

103

(Figueros 2014)

Could there possibly be anything else?

…more ?

please sir can I have some more…

Fetal Anaemia

‐ Peak Systolic Velocities

‐ 0 deg

‐ ? Example of fetal anaemia

Not used

‐ FGR

‐ Ignore (increased)

MCA - PSV

Paradigm shift

‐ Importance: Later onset

Ultrasound

‐ Screen/ Guide management

Build networks

‐ Skills / Protocols

Take care

‐ Not to normalise

The wrap-up !

107


17

Questions

Documents

asawebinar 1/04/2019 · 2019-04-02 · asawebinar 1/04/2019 7 42 This program is based on fetal weight equation proposed by Hadlock et al. [Hadlock FP, Harrist RB, Martinez-Poyer