actualizaciîn en crecimiento intrauterino restringido
TRANSCRIPT
Eduard Gratacós
www.fetalmedicinebarcelona.org/
ACTUALIZACIÓN EN CRECIMIENTO INTRAUTERINO RESTRINGIDO
BCNatal – Barcelona Center of Maternal-Fetal and Neonatal MedicineHospital Clínic and Hospital Sant Joan de Déu, Universitat de Barcelona
www.fetalmedicinebarcelona.org/
www.medicinafetalbarcelona.org/
0%
10%
20%
30%
40%
50%
FGR Unknown Others
25%
30%
45%
“SMALL FETUSES” AND MORTALITY AT TERM
Gardosi 2005 and 2013 Figueras 2012
www.fetalmedicinebarcelona.org/
Lindquist and Molin, 2005
n = 26 968
Gardosi et al. BMJ 2005 and 2013
Overall stillbirth / 1000 births: 2.4 in non-SGA vs19.8 in not detected SGA
www.fetalmedicinebarcelona.org/
Placental insufficiency = high risk of IUFD and fetal/neonatal acidosis
10
50
Feta
l wei
ght c
entil
e
“Small fetuses”
Placental “respiratory” smallness = risk distress + IUFD
Non-“respiratory” smallness = no distress/IUFD risk
0Risk of placental insufficiency
100
Fetal Smallness = higher risk of placental
insufficiency
www.fetalmedicinebarcelona.org/
1. Identificación del feto “pequeño”
2. Distinguir insuficiencia placentaria (CIR vs PEG)
3. Determinar seguimiento y parto
www.fetalmedicinebarcelona.org/
Neonatal vs Fetal GA “normal” weight in the same population
Mula 2013, Lobmaier 2013, Khalil 2014, Nicolaides 2015www.fetalmedicinebarcelona.org/
IMPROVING DETECTION & DEFINITION OF “RESTRICTION”Birthweight inverse relation with perinatal outcome AND brain-cardiac remodelling
RESE
ARCH
www.medicinafetalbarcelona.org
5-15% during 3rd trimester
30% perinatal complications; 10-15% term stillbirth
decrease2of2fetal2movements
25% IUGR
4% preterm delivery
1% stillbirth
70% Normal
stillbirth reduction OR 0.36
increase IUGR detection(IUGR > 36 w not diagnosed before)
www.fetalmedicinebarcelona.org/
Neonatal vs Fetal GA “normal” weight in the same population
www.fetalmedicinebarcelona.org/
1. Identificación del feto “pequeño”
2. Distinguir insuficiencia placentaria (CIR vs PEG)
3. Determinar seguimiento y parto
www.fetalmedicinebarcelona.org/
Placental insufficiency = high risk of IUFD and fetal/neonatal acidosis
10
50
Feta
l wei
ght c
entil
e
“Small fetuses”
Placental “respiratory” smallness = risk distress + IUFD
Non-“respiratory” smallness = no distress/IUFD risk
0Risk of placental insufficiency
100
Fetal Smallness = higher risk of placental
insufficiency
www.fetalmedicinebarcelona.org/
SGA Unknown (constitutional + others)
FGRPlacental insufficiency
ISOLATED FETAL SMALLNESS (= POORER PROGNOSIS)Perinatal 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.fetalmedicinebarcelona.org/
Constitutionally small Placental insufficiency Extrinsic cause
Primary fetal defect
SGA FGR
The discovery of UA and hemodynamics of FGR
FGR = abnormal UA Doppler
20 30 4025 35
0
N2cases
N2cases
UA Doppler +(EARLY-ONSET)
UA Doppler N(LATE-ONSET)
Savchev22013
www.medicinafetalbarcelona.org/
0
10
20
30
40
Neonatal acidosis CS for distress Abnormal NBAS Any
%
Figueras 2011
Evidence #1: SGA + NORMAL UA DOPPLER = POORER OUTCOMES
(n= 376)
www.medicinafetalbarcelona.org/
NON-DETECTED IUGR AND TERM
MORTALITYBarcelona
2005-2014
0%
10%
20%
30%
40%
50%
FGR Unknown Others
25%30%
45%
Stillbirth by relevant condition at birth (ReCoDe)Gardosi et al. BMJ 2005 and 2013
IUGR as relevant condition identified in 43-60%Overall stillbirth / 1000 births: 2.4 in non-SGA VS. 19.8 in not detected SGA
Evidence #2: “SGA” HAVE HIGHER RISK OF IUFD AT TERM
www.fetalmedicinebarcelona.org/
CIR = ¿Doppler AU anormal?
20 30 4025 35
0
N2cases
N2cases
UA Doppler +(EARLY-ONSET)
UA Doppler N(LATE-ONSET)
Savchev22013
Ya no
.
Risk of CS for distress and/or neonatal acidosis
N=509 SGA + 509 controls
www.fetalmedicinebarcelona.org/
UtA >p95
CPR <p5
EFW CENTILE <3
0%
10%
20%
30%
40%
50%
8%11%
40%
Controls All normal Any abnormal
%
Prognostic criteria for poor outcome among small fetuses with normal UA Doppler
Figueras 2012
IPUA=p80
Cerebroplacental ratio is more sensitive than UA or MCA alone
CPR <p5
IPMCA=p20
=+
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UtA >p95
CPR <p5 EFW CENTILE <3
Figueras 2012
CIR = PFE <p10 + cualquiera de
www.fetalmedicinebarcelona.org/
Distribution of cases when FGR = abnormal UA Doppler
Savchev 2013
www.fetalmedicinebarcelona.org/
Distribution of cases when FGR = abnormal CPR or UtA or EFW<p3
Savchev 2013
www.fetalmedicinebarcelona.org/
SGA Unknown (constitutional + others)
FGRPlacental 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.fetalmedicinebarcelona.org/
1. Identificación del feto “pequeño”
2. Distinguir insuficiencia placentaria (CIR vs PEG)
3. Determinar seguimiento y parto
Early-severeHigh risk IUFD preterm
PROBLEM: TIMING DELIVERYQ: Delivery? Next exam?
www.fetalmedicinebarcelona.org/
FGR = abnormal CPR or UtA or EFW<p3
Management = when should we deliver?
Savchev 2013
Late-mildNo IUFD <37w (risk at term)
PROBLEM: DETECTIONQ: Is it FGR or SGA?
www.fetalmedicinebarcelona.org/
FGR = abnormal CPR or UtA or EFW<p3
Savchev 2013
deliver when risks are:
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RATIONALE FOR AN INTEGRATED 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 markersDIFFERENCE FGR VS SGA
Prognostic/Acute markersINDICATION ABOUT THE SHORT-TERM RISK
OF IUFD/BRAIN INJURY
IVIIIIIIStage fetal deterioration
HIGHMILDMINIMALRisks of prematurity
BPP < 4
VERY&HIGH HIGH MODERATE
Mort.&&&& >90%& 50%& <10%Morb.& & >90%& & 50%
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<26w 26-28 28-30 30-34 34-37
FGRManagement protocol according to severity stages
Deliver'at Any&1me
Risk'of'IUFD/brain'injury
DV(a6),&cCTG,&CTG&dec
Stage IV
Mode CS
Follow=up Hours/Daily
30
DV>p95,&REDV
III
CS
162&d
34
AEDV,&AoI>95
II
CS&or&LI
2/w
37
EFW<p3,&CPR&<p5,&UtA>95
I
LI
1/w
LOW
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www.fetalmedicinebarcelona.org/
Delivery
Stage 1
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Primer objetivo:Identificación del feto “pequeño” (PFE<p10)
Segundo objetivo: Clasificar como CIR vs PEG con RCP, AUt y PFE<3.
Tercer objetivo: Decidir pauta seguimiento y momento del parto:
utilizar un protocolo integrado basado en estadíos.