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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