update on diagnosis and management of fetal growth...

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


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


UtA >p95

CPR


IUGR = abnormal CPR or UtA or EFW

Red Line EARLY IUGRRed Line LATE IUGR


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



1. Identify small fetus

2. FGR vs. SGA

3. Early vs. Late

4. Parameters for fetal follow-up

5. Stage-based management protocol



2. FGR vs. SGA

3. Early vs. Late

4. Parameters for fetal follow-up


Return


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



2. FGR vs. SGA

3. Early vs. Late


Return


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


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


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


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.



UtA >p95

CPR


Distribution of cases when IUGR = abnormal UA Doppler

Savchev 2013


Distribution of cases when IUGR = abnormal CPR or UtA or EFW



2. FGR vs. SGA

3. Early vs. Late


Return


IUGR

SGA?

20 30 4025 35

0

3

6 %

IUGR= low CPR or high UtA or EFW


FETAL DETERIORATION IN PLACENTAL INSUFFICIENCY

PLACENTAL DISEASE COMPENSATED HYPOXIA DECOMPENSATED HYPOXIA SERIOUS INJURYDEATH



Centralization


growth

MIDDLE CEREBRAL A. p95

cCTG: reduced short-term variability

Ao ISTHMUS >p95

UMBILICAL A. >p95



FETAL DETERIORATION IN PLACENTAL INSUFFICIENCY EARLY VS LATE IUGR (>34s)

PLACENTAL DISEASE COMPENSATED HYPOXIA DECOMPENSATED HYPOXIA SERIOUS INJURYDEATH



growth

UMBILICAL A. >p95

DUCTUS VENOSUS >p95 and a-

CTG / BPP ABNORMAL

Placental injury


IUGR

SGA?

20 30 4025 35

0

3

6 %

IUGR= low CPR or high UtA or EFW



2. FGR vs. SGA

3. Early vs. Late

4. Parameters for fetal follow up


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


30 % venous return

REFLECTS DIASTOLIC PRESSURE IN RIGHT (AND LEFT) HEART


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%



2. FGR vs. SGA

3. Early vs. Late

4. Parameters for fetal follow up


Return


IUGR = abnormal CPR or UtA or EFW

Red Line EARLY IUGRRed Line LATE IUGR


RATIONALE FOR A STAGE-BASED APPROACH TO THE MANAGEMENT OF FGR

PLACENTAL DISEASE HYPOXIA ACIDOSIS SERIOUS INJURY DEATH



Centralization


cCTG: reduced STV

Diagnostic/chronic markersEarly and Late IUGR

Prognostic/Acute markersEarly IUGR

IVIIIIIIStage fetal deteriorationHIGHMODERATELOWRisks of prematurity



Protocol IUGRFirst step: UtA + CPR + EFW = SGA or IUGR

CPRp95

MCAp95

I low EFW (p95


Delivery Any Ome 30 34 37

Mort. >90% 50% 90% 50%


p95UV puls REDV

(a) AEDV(b) AoI>95 CPR>p95

UtA>p95MCA


The main goal in FGR is identification

Small fetus (EFW

update on diagnosis and management of fetal growth...

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