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IUGR, AFI, and Aneuploidy IUGRAnomaliesPolyAneuploid X7 % XX32 % XX27 % XXX47 %

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Doppler

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IUGR: Maternal Doppler Uterine artery: S/D > 2.6 associated with IUGR, IUFD Elevated resistance index and IUGR: 70.6% sensitive 33.3% PPV

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IUGR: Fetal Dopplers Umbilical: rising S/D ratio = increasing placental resistance associated with fewer small arteries of tertiary placental villi Falling pulsatility index in head: indicates increased flow to brain Venous Dopplers: Cardiovascular performance

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IUGR: Fetal Dopplers Study of 43 IUGR fetuses: 85% had S/D ratios > 95th percentile decreased diastolic flow indicating high placental flow resistance Trudinger et al., Br J Obstet Gynaecol 92:39, 1985

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IUGR: Dopplers and Outcome When umbilical S/D known: lower PNM rates, fewer antenatal admissions, fewer inductions, fewer C/S no improvement noted for low risk pregnancies Divon & Ferber, Perinat Neonat Med 5:3, 2000

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Absent/Reversed EDV Doppler

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80% will have IUGR 36% PNM rate REDV: >70% placental arteries obliterated Mean time to delivery 7 days (0-49) Management: BMS, hospital bed rest, intensive monitoring, liberal delivery venous Dopplers

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MCA Doppler Technique Obtain axial section of the brain, including the thalami and the CSP. Sweep lower. The circle of Willis is visualized. MCA of one side is examined close to its origin from the internal carotid artery. The angle of insonance is kept as close as possible to 0 degrees.

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MCA Doppler: Dual Uses Fetal circulatory redistribution Pulsatility index, S/D ratio Fetal anemia Peak systolic velocity

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IUGR: Middle Cerebral Doppler Normally demonstrates low diastolic flow Increased diastolic flow: possible early indicator of fetal hypoxemia (Gudmundsson, 1996) Sign of cerebral redistribution with chronic hypoxemia (brain sparing effect) (Wladimiroff, 1986; Mari, 1992; Gramellini, 1992)

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IUGR: Middle Cerebral Doppler Normal MCAAbnormal MCA

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IUGR: Value of Doppler SGA fetuses with: Normal AFV Normal UmA S/D Normal MCA Dopplers >97% NPV for major negative perinatal sequellae Fong et al., Radiology 213:681, 1999.

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Fetal Venous Circulation

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Central Venous Circulation Doppler flow waveforms Fetal venous system has characteristic pulsations which reflect CVP

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DV UV Normal Venous Dopplers

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Abnormal Venous Dopplers DV UV

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IUGR: Venous Dopplers AEDV + umbilical vein pulsations = 54% mortality AEDV - umbilical vein pulsations = 10% mortality Indik, Obstet Gynecol 77:551, 1991 Venous atrial back flow waves are suggestive of metabolic Acidemia documented by PUBS Hecher et al., Am J Obstet Gynecol 173:10, 1995

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Fetal Diagn Ther. 2012;32(1-2):116-22

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IUGR: Fetal Response to UPI Respiratory/MetabolicHypoxia andAcidosis DysfunctionHypercarbia Compensation Decompensation Shunting:High right atrial pressure To: brain, heart, adrenalDV dilatation From: lungs, bowel, kidneyMyocardial dysfunction Ultrasound/Doppler:Doppler: Oligohydramnios venous/cardiac changes UmA and MCA DopplersBPP abnormal

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IUGR: Fetal Well-Being BPP use with IUGR: strong association with cord pH cascade of decompensation: BPP: lower rates of intervention compared to OCT/CST, with equal outcomes pHNR NST No FBM Movement ToneDead Man Float

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Doppler Findings With BPP < 6 Baschat, Ultrasound Obstet Gynecol 18:571, 2001

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Trends in Variables Before Delivery at