Management of IUGR Prof. Dr. Acar KOÇ

Transcription

1 Management of IUGR Prof. Dr. Acar KOÇ Ankara University School of Medicine Department of OB&GYN Department of Perinatology

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3 Definition and Diagnosis: SGA IUGR EFW: < 10th percentile EFW: < 10th percentile Does NOT show pathologic growth abnormalities Shows pathologic growth abnormalities

4 Diagnostic test results IUGR Anatomy survey & Amniotic fluid volume Normal anatomy, Normal AFI, or oligohydramnios Umbilical artery/mca Doppler If both Normal Cerebroplacental ratio Normal Repeat exam 2 weeks later Fetal anomaly Polihydramnios Elevated index, A/REDF Brain sparing Decreased ratio Normal Likely diagnosis Aneuploidy Genetic Syndromes Viral infection Placental insufficiency Constitutionally small fetus

5 Fetal Growth Restriction Wait? Deliver? Fetal compromise Neonatal complications DEATH Delivery threshold When risks for fetal compromise exceeds neonatal complications Monitoring interval Frequency of surveillance required to avoid unexpected stillbirth DEATH

6 Factors effecting the management of IUGR 1. Gestational age 2. Rate of clinical progression 3. Degree of fetal compromise

7 1. Gestational age

8 Survival & Mortality rates of normally grown fetuses (PPROM) Mercer 2003

9 Neonatal survival in IUGR fetuses Baschat, % / day inutero 2% / day inutero 604 IUGR < 33 weeks Overall mortality: 21% Intact survival: 58% Neonatal survival

10 Neonatal survival in IUGR fetuses Baschat, % / day inutero 2% / day inutero 604 IUGR < 33 weeks Overall mortality: 21% Intact survival: 58% Neonatal survival 50% AGA IUGR Neonatal survival 24 weeks 25 weeks Intact survival 25 weeks 27 weeks Intact survival rate

11 2. Rate of clinical progression

12 High resistance Abnormal perfusion Abnormal diffusion UA is commonly abnormal UtA is commonly abnormal UA is commonly normal MCA is commonly abnormal EARLY ONSET LATE ONSET

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15 Cerebroplacental Doppler Ratio (CPR) Centralization CPR = MCA PI UA PI A cerebral-umbilical artery Doppler ratio below 1.08 can be considered as evidence of centralization of cardiac output towards the fetal brain.

16 EARLY LATE Differences in clinical behaviour in IUGR fetuses Early onset < 34w Late Onset > 34w UA Rapidly abnormal Mildly abnormal MCA Less degree of brain sparing Higher degree of brain sparing DV Commonly abnormal Commonly normal Oligo More decresaed Less decreased

17 WAIT or DELIVER

18 547 Pregnancies weeks Unsure about delivery timing Immediate Delivery Delayed Delivery +4.9 days <30w +6.9 days >31w C-section rate 91% < Fetal demise in-utero 2 < Neonatal death Perinatal mortality 29 NS 27 Prematurity realated comp 17 < < 30w

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20 Oxford Vermont Network Comparing steroid benefits in preterm IUGR & AGA VLBW infants IUGR vsaga RDS 1.19 ( ) NEC 1.27 ( ) IVH 1.13 ( ) Neonatal Death 2.77 ( ) IUGR & AGA equally benefit from steroids ADMINISTER CORTICOSTEROIDS < 34weeks

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22 3. Degree of fetal deterioration

23 Biophysical Profile (BPP) MEASUREMENT NORMAL (2 points) ABNORMAL (0 points) Non Stress Test (NST) Amniotic Fluid Index (AFI) > 2 heart rate increases of at least 15 beats/min and lasts > 15 sec. minute. The amniotic fluid index is between 5 cm and 24 cm. Only 1 heart rate increase, or the heart rate does not increase by more than 15 beats Not enough amniotic fluid is seen in the uterus. Breathing movement Body movement 1 or more breathing movements last at least 60 seconds. 3 or more movements of the arms, legs, or body No breathing movement or less than 60 seconds Less than 3 movements of the arms, legs, or body Muscle tone Arms and legs are usually flexed and the head rests on the chest. The arms, legs, or spine are extended, or a hand is open.

24 Short Term Variation STV (ms) < > 3.0 Gestation (weeks) Metabolic acidemia ph<7.12, BD >12mmol/L 10.3 % 4.3 % 2.7 % Intrauterine Death 24.1 % 4.3 % 0.0 %

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26 Integration of venous Doppler and cctg-stv Ductus Venosus & CTG-STV n Alive Intra Uterine Death Neonatal Death Perinatal Mortality Both Abnormal % Both Normal/ One Abnormal % TOTAL % Hecker 2001

27 Integration of venous Doppler and BPP 584 IUGR fetuses, 1722 exam Outcome Abnormal Venous Doppler Abnormal BPP Both Tests Stillbirth 81 % 70 % 89 % Acidemia 71 % 63 % 88 % Intraventricular hemorrhage 53 % 42 % 73 % Neonatal death 74 % 55 % 94 % Baschat 2007

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29 Enrollment criteria: AC < 10 percentile & abnormal UA Doppler 503 women, weeks DELIVERY CRITERIA cctg STV ( weeks < 3.5 ms ) ( weeks < 4 ms ) DV high resistance or Abnormal STV DV rev. a-wave or Abnormal STV Survial without impairment 85% 90% 95% Impairment at age 2 15% 9% 5%

30 Progression to stillbirth EARLY ONSET LATE ONSET 2-4 weeks 4-6 weeks 7 days to stillbirth 4 days to stillbirth

31 Signs of disease acceleration EARLY ONSET Brain sparing Loss of UA EDV Oligohydramnios Abnormal DV Doppler LATE ONSET Oligohydramnios Brain sparing Nonreactive NST If you don t deliver, then increase monitoring interval

32 Monitoring interval EARLY ONSET LATE ONSET Compensated Weekly Weekly Hypoxemia 2-3/w Oligohydramnios Descelerative NST New onset Brain sparing 2-3/w Acidemia Daily STILLBIRTH Abnormal BPP Deliver at any age Abnormal BPP

33 Timing of delivery

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39 Conclusion: IUGR is a challenging problem for obstetricians The physiopathology of early onset and late onset IUGR is different No single test helps for an optimal management Combination of tests may increase the diagnosis of deterioration The current management goal is to optimize the timing of delivery to minimize hypoxemia and maximize gestational age and fetal outcome with an appropriate monitoring intervals.

40 Thank You Prof. Dr. Acar KOÇ Ankara University School of Medicine Department of OB&GYN Department of Perinatology