Upload
others
View
2
Download
0
Embed Size (px)
Citation preview
www.fetalmedicinebarcelona.org/
UPDATE ON DIAGNOSIS AND MANAGEMENT OF
FETAL GROWTH RESTRICTIONEduard Gratacos
Center for Maternal-Fetal Medicine and NeonatologyHospital Clinic & Hospital Sant Joan de Deu - University de Barcelona
www.fetalmedicinebarcelona.org
http://www.fetalmedicinebarcelona.orghttp://www.fetalmedicinebarcelona.org
www.medicinafetalbarcelona.org/
Neonatal and Fetal GA-adjusted “normal” weight in the same population
www.medicinafetalbarcelona.org/
SGA Unknown (constitutional + others)
IUGRPlacental insufficiency
ISOLATED FETAL SMALLNESS = POORER PROGNOSISPerinatal and Long-term Outcomes
Exclude extrinsic cause
Exclude primary fetal defect
Poor perinatal outcome + IUFD(Doppler) Signs of adaptation
Perinatal outcome normal - No IUFDNO signs of adaptation
FGR vs. SGA: DIFFERENT MANAGEMENT
www.medicinafetalbarcelona.org/
UtA >p95
CPR
www.medicinafetalbarcelona.org/
IUGR = abnormal CPR or UtA or EFW
Red Line EARLY IUGRRed Line LATE IUGR
www.medicinafetalbarcelona.org/
RATIONALE FOR A STAGE-BASED APPROACH TO THE MANAGEMENT OF FGR
PLACENTAL DISEASE HYPOXIA ACIDOSIS SERIOUS INJURY DEATH
cardiac ischemiaDiastolic failure
Systolic cardiac failure
Centralization
Increment placental impedance
cCTG: reduced STV
Diagnostic/chronic markersEarly and Late IUGR
Prognostic/Acute markersEarly IUGR
IVIIIIIIStage fetal deteriorationHIGHMODERATELOWRisks of prematurity
http://www.fetalmedicinebarcelona.orghttp://www.fetalmedicinebarcelona.org
www.medicinafetalbarcelona.org/
1. Identify small fetus
2. FGR vs. SGA
3. Early vs. Late
4. Parameters for fetal follow-up
5. Stage-based management protocol
www.medicinafetalbarcelona.org/
1. Identify small fetus
2. FGR vs. SGA
3. Early vs. Late
4. Parameters for fetal follow-up
5. Stage-based management protocol
Return
www.medicinafetalbarcelona.org/
Neonatal and Fetal GA-adjusted “normal” weight in the same population
Mula 2013, Lobmaier 2013www.medicinafetalbarcelona.org/
IMPROVING DETECTION: THE DEFINITION OF “RESTRICTION”Birthweight inverse relation with perinatal outcome AND brain-cardiac remodelling
!
INTEGRATED 3T SCREENING FOR LATE-PREGNANCY COMPLICATIONSLate-PE, Late-IUGR, Stillbirth
www.medicinafetalbarcelona.org/
1. Identify small fetus
2. FGR vs. SGA
3. Early vs. Late
4. Stage-based management protocol
Return
www.medicinafetalbarcelona.org/
SGA Unknown (constitutional + others)
IUGRPlacental insufficiency
ISOLATED FETAL SMALLNESS = POORER PROGNOSISPerinatal and Long-term Outcomes
Exclude extrinsic cause
Exclude primary fetal defect
Poor perinatal outcome + IUFD(Doppler) Signs of adaptation
Perinatal outcome normal - No IUFDNO signs of adaptation
FGR vs. SGA: DIFFERENT MANAGEMENT
www.medicinafetalbarcelona.org/
Constitutionally small Placental insufficiency Extrinsic cause
Primary fetal defect
SGA FGR
The discovery of UA and hemodynamics of IUGR
FGR = abnormal UA Doppler
20 30 4025 35
0
N cases
N cases
UA Doppler +(EARLY-ONSET)
UA Doppler N(LATE-ONSET)
Savchev 2013
www.medicinafetalbarcelona.org/
0
10
20
30
40
Neonatal acidosis CS for distress Abnormal NBAS Any
%
Figueras 2011
SGA: proportion of perinatal adverse outcomes in 376 consecutive cases
www.medicinafetalbarcelona.org/
IMPACT OF NON-DETECTED IUGR ON LATE FETAL MORTALITYBarcelona2005-2010
0%
10%
20%
30%
40%
50%
FGR Unknown Others
25%30%
45%
Classification of stillbirth by relevant condition at birth (ReCoDe): population-based cohort studyGardosi et al. BMJ 2005 and 2013
IUGR as relevant condition identified in 43-60%
Overall stillbirth rate (/ 1000 births) 4.2, but only 2.4 in non-SGA pregnancies, increasing to 9.7 with antenatally detected IUGR and 19.8 in not detected IUGR.
http://www.fetalmedicinebarcelona.orghttp://www.fetalmedicinebarcelona.org
www.medicinafetalbarcelona.org/
UtA >p95
CPR
www.medicinafetalbarcelona.org/
Distribution of cases when IUGR = abnormal UA Doppler
Savchev 2013
www.medicinafetalbarcelona.org/
Distribution of cases when IUGR = abnormal CPR or UtA or EFW
www.medicinafetalbarcelona.org/
1. Identify small fetus
2. FGR vs. SGA
3. Early vs. Late
4. Stage-based management protocol
Return
www.fetalmedicinebarcelona.org/
IUGR
SGA?
20 30 4025 35
0
3
6 %
IUGR= low CPR or high UtA or EFW
www.medicinafetalbarcelona.org/
FETAL DETERIORATION IN PLACENTAL INSUFFICIENCY
PLACENTAL DISEASE COMPENSATED HYPOXIA DECOMPENSATED HYPOXIA SERIOUS INJURYDEATH
cardiac ischemiaDiastolic failure
Systolic cardiac failure
Centralization
Increment placental impedance
growth
MIDDLE CEREBRAL A. p95
cCTG: reduced short-term variability
Ao ISTHMUS >p95
UMBILICAL A. >p95
http://www.fetalmedicinebarcelona.orghttp://www.fetalmedicinebarcelona.org
www.medicinafetalbarcelona.org/
FETAL DETERIORATION IN PLACENTAL INSUFFICIENCY EARLY VS LATE IUGR (>34s)
PLACENTAL DISEASE COMPENSATED HYPOXIA DECOMPENSATED HYPOXIA SERIOUS INJURYDEATH
cardiac ischemiaDiastolic failure
Systolic cardiac failure
growth
UMBILICAL A. >p95
DUCTUS VENOSUS >p95 and a-
CTG / BPP ABNORMAL
Placental injury
www.fetalmedicinebarcelona.org/
IUGR
SGA?
20 30 4025 35
0
3
6 %
IUGR= low CPR or high UtA or EFW
www.medicinafetalbarcelona.org/
1. Identify small fetus
2. FGR vs. SGA
3. Early vs. Late
4. Parameters for fetal follow up
4. Stage-based management protocol
Return
umbilical arterynormal and anormal hemodynamics
DS
Cardiac pump normal function
Cardiac pump abnormal function
Placental status
middle cerebral arterynormal and abnormalhemodynamics
[marked vasodilation]
[normal waveform]
[mild vasodilation]
Normal oxygenation
hypoxia
www.medicinafetalbarcelona.org/
30 % venous return
REFLECTS DIASTOLIC PRESSURE IN RIGHT (AND LEFT) HEART
http://www.fetalmedicinebarcelona.orghttp://www.fetalmedicinebarcelona.org
ductus venosusnormal and abnormal hemodynamics
Venous vessel: pulsation due to retrograde pressure
S DA
ductus venosusnormal and abnormal hemodynamics
compliance right chambers: effect sobre
on venous return
DS A
P
P
P
P
Myocardial ischemia
compliance
no
Perinatal >90% 30-‐40%
Perinatal >90% 30-‐40%
www.medicinafetalbarcelona.org/
1. Identify small fetus
2. FGR vs. SGA
3. Early vs. Late
4. Parameters for fetal follow up
5. Stage-based management protocol
Return
www.medicinafetalbarcelona.org/
IUGR = abnormal CPR or UtA or EFW
Red Line EARLY IUGRRed Line LATE IUGR
www.medicinafetalbarcelona.org/
RATIONALE FOR A STAGE-BASED APPROACH TO THE MANAGEMENT OF FGR
PLACENTAL DISEASE HYPOXIA ACIDOSIS SERIOUS INJURY DEATH
cardiac ischemiaDiastolic failure
Systolic cardiac failure
Centralization
Increment placental impedance
cCTG: reduced STV
Diagnostic/chronic markersEarly and Late IUGR
Prognostic/Acute markersEarly IUGR
IVIIIIIIStage fetal deteriorationHIGHMODERATELOWRisks of prematurity
http://www.fetalmedicinebarcelona.orghttp://www.fetalmedicinebarcelona.org
www.medicinafetalbarcelona.org/
Protocol IUGRFirst step: UtA + CPR + EFW = SGA or IUGR
CPRp95
MCAp95
I low EFW (p95
http://www.fetalmedicinebarcelona.orghttp://www.fetalmedicinebarcelona.org
Delivery Any Ome 30 34 37
Mort. >90% 50% 90% 50%
www.medicinafetalbarcelona.org/
p95UV puls REDV
(a) AEDV(b) AoI>95 CPR>p95
UtA>p95MCA
www.medicinafetalbarcelona.org/
The main goal in FGR is identification
Small fetus (EFW