ultrasound evaluation for fetal growth restriction€¦ · robson er, human growth vol 1:...
TRANSCRIPT
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Lavenia Carpenter, MD Associate Professor
Division of Maternal-Fetal Medicine Department of Obstetrics and Gynecology
Vanderbilt University
Disclosures None
Objectives Why screen
Who to screen
When to screen/when to test
What test(s) to use
Where are we going
Definitions Fetal growth restriction – Failure of a fetus to reach its
growth potential
Small for gestational age newborns – EFW < 10th% or AC< 10th%
Severe SGA - < 3rd%
LBW- < 2500 gms
WHY?
Risk of fetal death
1.5% with EFW< 10th%
2.5% with EFW < 5th%
Morbidity – Neonatal: hypoglycemia, hyperbilirubinemia, hyopthermia, IVH, NEC, seizures, sepsis, RDS ….. neonatal death
Morbidity – Childhood: congnitive delay and Adulthood: higher risk for chronic disease (Barker hypothesis)
Creasy and Resnik's Maternal-Fetal Medicine: Principles and Practice. Resnik, Robert, MD; Creasy, Robert K., MD.Published January 1, 2014. Pages 743-755.e4. © 2014. Morbidity and mortality in 1560 small-for-gestational-age fetuses.
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Overall stillbirth rate of 4.2/1000 but 2.4/1000 without FGR Average delivery 10 days earlier when detected
Population-Based Estimates of In-Unit Survival for Very Preterm Infants - female
Population-Based Estimates of In-Unit Survival for Very Preterm Infants - male
Balance of risks/benefits of early delivery
stillbirth
neonatal demise morbidity
Barker hypothesis
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Barker hypothesis Barker hypothesis
Thrifty phenotype
Cheryl Lyn Walker & Shuk-mei Ho; Nature Reviews Cancer 12, 479-486 (July 2012)
WHO? Maternal risk factors
History of FGR
Diabetes, hypertension, autoimmune disorders, renal disease
Tobacco or other substance use
Low pre-pregnancy birth weight
High altitude
Pregnancy course
Poor weight gain
Preeclampsia
Short fundal height
Etiologies
ENVIRONMENT Infections Altitude Nutrition
MATERNAL Chronic illnesses Substance abuse Preeclampsia Age Parity Malnutrition
FETAL Aneuploidy Genetic syndromes Multiples Gender
PL
AC
EN
TA
L
Correlation for birth weight Between r
Monozygotic twins 0.54
Full siblings 0.52
Half siblings common mother 0.58
Half siblings common father 0.10
First cousins common maternal grandparents 0.135
First cousins common paternal grandparents 0.015
Robson ER, Human growth Vol 1: Principles and prenatal growth New York: Plenum press 1978
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Maternal constraint Small breed embryo transplanted to large breed uterus
will growth larger than a small breed embryo remaining in a small breed uterus
Multiple gestation in humans
Creasy and Resnik's Maternal-Fetal Medicine: Principles and Practice. Resnik, Robert, MD; Creasy, Robert K., MD.Published January 1, 2014. Pages 743-755.e4. © 2014. Median growth rate curves for single and multiple births in California, 1970-1976
Maternal nutrition Starvation effect most pronounced in third trimester
(Holland example)
Starvation in the first trimester with normal birthweight daughters but small granddaughters – epigenetic effects
Fetus Genetic potential
Creasy and Resnik's Maternal-Fetal Medicine: Principles and Practice. Resnik, Robert, MD; Creasy, Robert K., MD.Published January 1, 2014. Pages 743-755.e4. © 2014. Weight-for-age gender-specific curves (solid line) for girls (A) and boys (B) compared with Lubchenco unisex curves ( dashed line) starting at 24 weeks.
Placenta Placental growth (mass) in first half of pregnancy with
remodeling (terminal villi) in later half of pregnancy
Fetal growth in second half of pregnancy
Fetomaternal immune cross-talk and its consequences for maternal and offspring's health Petra C Arck1, & Kurt Hecher1, Journal name:Nature Medicine Volume: 99, Pages:548–556 Year published:(2013) DOI:
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Placental surface areas at different gestational ages. () areas of intermediate villi; () areas of terminal villi. (Adapted from The Physiology of the Human Placenta, by Page K, Figure 2.7, published by UCL press).
Illustration of uterine and placental vasculature in the non-pregnant, pregnant and immediate post-partum state. Normal pregnancy is characterized by the formation of large arterio-venous shunts that persist in the immediate post-partum period. By contrast pregnancies complicated by severe preeclampsia are characterized by minimal arterio-venous shunts, and thus narrower uterine arteries characterized with “low flow and high resistance.” Red shading = arterial; blue shading = venous. Adapted from Burton et al. Placenta 2009; 30 (6), 473-482. Adapted from Placenta, Burton et al. 2009
When Maternal risk factors
Poor weight gain
Size less than dates (fundal height)
Pregnancy associated hypertension
Abnormal placentation
Abnormal serum screening
Uncertainty in dating
Timing of testing dependent upon risk factor
EGA Clinical or Sonographic +/- 2SD
IVF +/- 1 day
Ovulation induction or AI +/- 3 days
Ultrasound EGA < 8 6/7 (CRL) +/- 5 days
9-13 6/7 (CRL) +/- 7 days
14-15 6/7 (BPD, HC, AC, FL) +/- 7 days
16-21 6/7 (BPD, HC, AC, FL) +/- 10 days
22-27 6/7 (BPD, HC, AC, FL) +/- 14 days
>28 (BPD, HC, AC, FL) +/- 21 days
ACOG committee opinion Estimating Due Date No. 611 Oct 2014
Creasy and Resnik's Maternal-Fetal Medicine: Principles and Practice. Resnik, Robert, MD; Creasy, Robert K., MD.Published January 1, 2014. Pages 743-755.e4. © 2014. Fetal weight as a function of gestational age by selected references.
<10th% <3rd%
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WHAT (test to use)? Cardiotocography or NST
Biophysical profile
Doppler studies
Nonstress test (NST)
Moderate variability Accelerations associated with maternal palpation FMs (accelerations graded for gestation) on 20-minute NST
FM and accelerations not coupled Insufficient accelerations, absent accelerations, or decelerative trace Minimal or absent variability
Devoe, L, Glob. libr. women's med., (ISSN: 1756-2228) 2008; DOI 10.3843/GLOWM.10210
Fetal Variable Normal Behavior (score = 2) Abnormal Behavior (score = 0)
Fetal breathing movements (FBMs)
Intermittent, multiple episodes of more than 30 sec within a 30-min biophysical profile (BPP) time frame Hiccups count If continuous FBMs for 30 min, rule out fetal acidosis
Continuous breathing without cessation Completely absent breathing or no sustained episodes
Body or limb movements
At least three discrete body movements in 30 min Continuous, active movement episodes equal a single movement Includes fine motor movements, rolling movements, and so on, but not rapid eye movements or mouthing movements
Three or fewer body or limb movements in a 30-min observation period
Fetal tone or posture
Demonstration of active extension with rapid return to f lexion of fetal limbs and brisk repositioning or trunk rotation Opening and closing of hand or mouth, kicking, and so on
Low-velocity movement only Incomplete f lexion, f laccid extremity positions, abnormal fetal posture Must score 0 when fetal movement (FM) is completely absent
Amniotic f luid evaluation
At least one pocket larger than 2 cm with no umbilical cord (text discusses subjectively decreased f luid)
No cord-free pocket greater than 2 cm or multiple definite elements of subjectively reduced amniotic f luid volume
Creasy and Resnik's Maternal-Fetal Medicine: Principles and Practice. Bahtiyar, Mert Ozan, MD; Copel, Joshua A., MD.Published January 1, 2014. © 2014.
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Creasy and Resnik's Maternal-Fetal Medicine: Principles and Practice. Bahtiyar, Mert Ozan, MD; Copel, Joshua A., MD.Published January 1, 2014. © 2014.
BPP – gradual hypoxia concept NST and FBM
Movement
Tone
AFV (chronic)
Vintzileos et al. Obstet Gynecol 1987;70:196
BPP and cord pH
BPP Interpretation Predicted PNM/1000 * Recommended Management
10/10, 8/8, 8/10 (AFV normal)
No evidence of fetal asphyxia
Less than 1/1000
No acute intervention on fetal basis; serial testing indicated by disorder-specific protocols
8/10-oligo Chronic fetal compromise likely (unless ROM is proved)
89/1000
For absolute oligohydramnios, prove normal urinary tract, disprove undiagnosed ROM, consider antenatal steroids, and then deliver
6/10 (AFV normal) Equivocal test; fetal asphyxia is not excluded
Depends on progression (61/1000 on average)
Repeat testing immediately, before assigning final value If score is 6/10, then 10/10, in two continuous 30-minute periods, manage as 10/10 For persistent 6/10, deliver the mature fetus, repeat within 24 hr in the immature fetus, then deliver if less than 6/10
4/10 Acute fetal asphyxia likely
91/1000 Deliver by obstetrically appropriate method, with continuous monitoring If AFV-oligo, acute on
chronic asphyxia very likely
2/10 Acute fetal asphyxia likely with chronic decompensation
125/1000 Deliver for fetal indications (frequently requires cesarean section)
0/10 Severe, acute asphyxia virtually certain
600/1000 If fetal status is viable, deliver immediately by cesarean section
Creasy and Resnik's Maternal-Fetal Medicine: Principles and Practice. Bahtiyar, Mert Ozan, MD; Copel, Joshua A., MD.Published January 1, 2014. © 2014.
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BPP and medications Beta andrenergics
Possible increase in FBM
Steroids Reduction in FBM and FM and non-reactive NST has been
described
Magnesium sulfate Possible decrease in FBM and NST
Opiods
Fasting Hyperglycemia may increase FBM in presence of acidemia
fasting may decrease FBM
Signore C, Freeman R and Spong C. Obstet Gynecol. Mar 2009; 113(3): 687–701
Risk for mortality morbidity due to prematurity http://www.nichd.nih.gov/about/org/der/branches/p
pb/programs/epbo/pages/epbo_case.aspx
http://www.nichd.nih.gov/about/org/der/branches/ppb/programs/epbo/pages/epbo_case.aspx
<10th% <3rd%
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Umbilical artery
Doppler studies Umbilical artery
Middle cerebral artery
Ductus venosus
Uterine artery
http://www.vanderbilthealth.com/includes/healthtopics/calc.php?
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Creasy and Resnik's Maternal-Fetal Medicine: Principles and Practice. Bahtiyar, Mert Ozan, MD; Copel, Joshua A., MD.Published January 1, 2014. © 2014.
Middle cerebral artery
Creasy and Resnik's Maternal-Fetal Medicine: Principles and Practice. Bahtiyar, Mert Ozan, MD; Copel, Joshua A., MD.Published January 1, 2014. Pages 211-217.e1. © 2014.
Cerebroplacental ratio (CPR) in relation to gestational age. The curves indicate the 5th, 10th, 90th, and 95th percentile values for pregnancies with and without morbidity and perinatal complications. The interval between Doppler imaging and delivery was less than 2 weeks. Open circles, <10th percentile, no morbidity; filled circles, <10th percentile, with morbidity.
Abnormal MCA
Abnormal umbilical
artery
Abnormal
ductus venosus
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TRUFFLE 2011 “Although the difference in proportion of infants
surviving without neuroimpairment was non-significant at the primary endpoint, timing of delivery based on the study protocol using late changes in the DV waveform might produce an improvement in developmental outcomes at 2 years of age.”
Where? Expansion in use of customized fetal growth charts
Cell free fetal DNA for evaluation of genetic syndromes
Biochemical markers to help distinguish small normal from placental dysyfunction
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Placenta on chip
For Immediate Release: Thursday, June 18, 2015 Researchers design placenta-on-a-chip to better understand pregnancy http://www.nih.gov/news/health/jun2015/nichd-18.htm
THANK YOU!