UPDATE ON DIAGNOSIS AND MANAGEMENT OF FETAL GROWTH RESTRICTION
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1 UPDATE ON DIAGNOSIS AND MANAGEMENT OF FETAL GROWTH RESTRICTION Eduard Gratacos Servicio de Medicina Maternofetal Hospital Clinic y Hospital Sant Joan de Deu - Universidad de Barcelona
2 1. Identify small fetus 2. FGR vs. SGA 3. Early vs. Late 4. Stage-based management protocol
3 1. Identify small fetus 2. FGR vs. SGA 3. Early vs. Late 4. Stage-based management protocol
4 Neonatal and Fetal GA-adjusted normal weight in the same population
5 Neonatal and Fetal GA-adjusted normal weight in the same population
6 1. Identify small fetus 2. FGR vs. SGA 3. Early vs. Late 4. Stage-based management protocol
7 Exclude primary fetal defect Exclude extrinsic cause ISOLATED FETAL SMALLNESS = POORER PROGNOSIS Perinatal and Long-term Outcomes
8 Exclude primary fetal defect Exclude extrinsic cause ISOLATED FETAL SMALLNESS = POORER PROGNOSIS Perinatal and Long-term Outcomes Poor perinatal outcome + IUFD (Doppler) Signs of adaptation
9 Exclude primary fetal defect Exclude extrinsic cause ISOLATED FETAL SMALLNESS = POORER PROGNOSIS Perinatal and Long-term Outcomes Poor perinatal outcome + IUFD (Doppler) Signs of adaptation Perinatal outcome normal - No IUFD NO signs of adaptation
10 Exclude primary fetal defect Exclude extrinsic cause ISOLATED FETAL SMALLNESS = POORER PROGNOSIS Perinatal and Long-term Outcomes Poor perinatal outcome + IUFD (Doppler) Signs of adaptation IUGR Placental insufficiency Perinatal outcome normal - No IUFD NO signs of adaptation SGA Unknown (constitutional + others)
11 Exclude primary fetal defect Exclude extrinsic cause ISOLATED FETAL SMALLNESS = POORER PROGNOSIS Perinatal and Long-term Outcomes Poor perinatal outcome + IUFD (Doppler) Signs of adaptation IUGR Placental insufficiency Perinatal outcome normal - No IUFD NO signs of adaptation SGA Unknown (constitutional + others)
12 Exclude primary fetal defect Exclude extrinsic cause ISOLATED FETAL SMALLNESS = POORER PROGNOSIS Perinatal and Long-term Outcomes Poor perinatal outcome + IUFD (Doppler) Signs of adaptation IUGR Placental insufficiency Perinatal outcome normal - No IUFD NO signs of adaptation SGA Unknown (constitutional + others) FGR vs. SGA: DIFFERENT MANAGEMENT
13 The discovery of UA and hemodynamics of IUGR Constitutionally small Placental insufficiency Extrinsic cause Primary fetal defect SGA FGR
14 The discovery of UA and hemodynamics of IUGR Constitutionally small Placental insufficiency Extrinsic cause Primary fetal defect SGA FGR N cases 0 N cases
15 The discovery of UA and hemodynamics of IUGR Constitutionally small Placental insufficiency Extrinsic cause Primary fetal defect SGA FGR N cases UA Doppler + (EARLY-ONSET) 0 N cases
16 The discovery of UA and hemodynamics of IUGR Constitutionally small Placental insufficiency Extrinsic cause Primary fetal defect SGA FGR N cases UA Doppler + (EARLY-ONSET) 0 UA Doppler N (LATE-ONSET) N cases Savchev 2013
17 The discovery of UA and hemodynamics of IUGR Constitutionally small Placental insufficiency Extrinsic cause Primary fetal defect SGA FGR N cases UA Doppler + (EARLY-ONSET) 0 UA Doppler N (LATE-ONSET) N cases Savchev 2013 FGR = abnormal UA Doppler
18 SGA: proportion of perinatal adverse outcomes in 376 consecutive cases % Neonatal acidosis CS for distress Abnormal NBAS Any Figueras 2011
19 50% 45% IMPACT OF NON- DETECTED IUGR ON LATE FETAL MORTALITY Hospital Clínic Barcelona % 30% 20% 10% 30% 25% 0% FGR Unknown Others Relevant Condition ReCoDe
20 50% 45% IMPACT OF NON- DETECTED IUGR ON LATE FETAL MORTALITY Hospital Clínic Barcelona % 30% 20% 10% 30% 25% 0% FGR Unknown Others Relevant Condition ReCoDe Impact of growth restriction in late pregnancy stillbirth Gardosi et al. BMJ 2005, 2013 N=2625 stillbirths FGR as relevant condition identified in 43-60%
21 Prognostic criteria of poor outcome -SGA CS for distress and/or neonatal acidosis UtA >p95 CPR <p5 EFW CENTILE <3 N=447 SGA controls Figueras 2012
22 Prognostic criteria of poor outcome -SGA CS for distress and/or neonatal acidosis UtA >p95 CPR <p5 EFW CENTILE <3 N=447 SGA controls Figueras 2012
23 Prognostic criteria of poor outcome -SGA CS for distress and/or neonatal acidosis UtA >p95 CPR <p5 EFW CENTILE <3 N=447 SGA controls 50% 40% 30% 20% 10% 0% Controls All normal Any abnormal Figueras 2012
24 Prognostic criteria of poor outcome -SGA CS for distress and/or neonatal acidosis UtA >p95 CPR <p5 EFW CENTILE <3 N=447 SGA controls 50% 40% 30% 20% 10% 8% 0% Controls All normal Any abnormal Figueras 2012
25 Prognostic criteria of poor outcome -SGA CS for distress and/or neonatal acidosis UtA >p95 CPR <p5 EFW CENTILE <3 N=447 SGA controls 50% 40% 30% 20% 10% 8% 11% 0% Controls All normal Any abnormal Figueras 2012
26 Prognostic criteria of poor outcome -SGA CS for distress and/or neonatal acidosis UtA >p95 CPR <p5 EFW CENTILE <3 N=447 SGA controls 50% 40% 40% 30% % 20% 10% 8% 11% 0% Controls All normal Any abnormal Figueras 2012
27 Distribution of cases when IUGR = abnormal UA Doppler Savchev 2013
28 Distribution of cases when IUGR = abnormal CPR or UtA or EFW<p3 Savchev 2013
29 1. Identify small fetus 2. FGR vs. SGA 3. Early vs. Late 4. Stage-based management protocol
30 IUGR= low CPR or high UtA or EFW<p3 or low PlGF 6 % SGA? 3 IUGR
31 IUGR= low CPR or high UtA or EFW<p3 or low PlGF 6 % SGA? 3 IUGR
32 IUGR= low CPR or high UtA or EFW<p3 or low PlGF 6 % SGA? 3 IUGR EARLY IUGR (1%) LATE IUGR (5-7%)
33 IUGR= low CPR or high UtA or EFW<p3 or low PlGF 6 % SGA? 3 IUGR EARLY IUGR (1%) LATE IUGR (5-7%) PROBLEM: MANAGEMENT PROBLEM: DIAGNOSIS
34 IUGR= low CPR or high UtA or EFW<p3 or low PlGF 6 % SGA? 3 IUGR EARLY IUGR (1%) LATE IUGR (5-7%) PROBLEM: MANAGEMENT Placental disease: high (UA+, PE high) PROBLEM: DIAGNOSIS Placental disease: low (UA-, PE low)
35 IUGR= low CPR or high UtA or EFW<p3 or low PlGF 6 % SGA? 3 IUGR EARLY IUGR (1%) LATE IUGR (5-7%) PROBLEM: MANAGEMENT Placental disease: high (UA+, PE high) Hypoxia ++: systemic CV adaptation PROBLEM: DIAGNOSIS Placental disease: low (UA-, PE low) Hypoxia +/-: central CV adaptation
36 IUGR= low CPR or high UtA or EFW<p3 or low PlGF 6 % SGA? 3 IUGR EARLY IUGR (1%) LATE IUGR (5-7%) PROBLEM: MANAGEMENT Placental disease: high (UA+, PE high) Hypoxia ++: systemic CV adaptation Tolerance to hypoxia. Natural history PROBLEM: DIAGNOSIS Placental disease: low (UA-, PE low) Hypoxia +/-: central CV adaptation Low tolerance: no natural history
37 IUGR= low CPR or high UtA or EFW<p3 or low PlGF 6 % SGA? 3 IUGR EARLY IUGR (1%) LATE IUGR (5-7%) PROBLEM: MANAGEMENT Placental disease: high (UA+, PE high) Hypoxia ++: systemic CV adaptation Tolerance to hypoxia. Natural history High mortality and morbidity PROBLEM: DIAGNOSIS Placental disease: low (UA-, PE low) Hypoxia +/-: central CV adaptation Low tolerance: no natural history Low mortality but poor long outcome.
38 FETAL DETERIORATION IN PLACENTAL INSUFFICIENCY PLACENTAL DISEASE COMPENSATED HYPOXIA DECOMPENSATED HYPOXIA SERIOUS INJURY DEATH Increment placental impedance CPR <p5 UMBILICAL A. >p95 Centralization MIDDLE CEREBRAL A. <p5 cardiac ischemia Diastolic failure growth CTG ABNORMAL Systolic cardiac failure
39 FETAL DETERIORATION IN PLACENTAL INSUFFICIENCY PLACENTAL DISEASE COMPENSATED HYPOXIA DECOMPENSATED HYPOXIA SERIOUS INJURY DEATH Increment placental impedance CPR <p5 UMBILICAL A. >p95 Centralization MIDDLE CEREBRAL A. <p5 cardiac ischemia Diastolic failure growth DUCTUS VENOSUS >p95 and a- CTG ABNORMAL Systolic cardiac failure
40 FETAL DETERIORATION IN PLACENTAL INSUFFICIENCY PLACENTAL DISEASE COMPENSATED HYPOXIA DECOMPENSATED HYPOXIA SERIOUS INJURY DEATH Increment placental impedance UTERINE A. >p95 CPR <p5 UMBILICAL A. >p95 Centralization MIDDLE CEREBRAL A. <p5 cardiac ischemia Diastolic failure growth DUCTUS VENOSUS >p95 and a- CTG ABNORMAL Systolic cardiac failure
41 FETAL DETERIORATION IN PLACENTAL INSUFFICIENCY PLACENTAL DISEASE COMPENSATED HYPOXIA DECOMPENSATED HYPOXIA SERIOUS INJURY DEATH Increment placental impedance UTERINE A. >p95 CPR <p5 UMBILICAL A. >p95 Centralization MIDDLE CEREBRAL A. <p5 cardiac ischemia Diastolic failure growth DUCTUS VENOSUS >p95 and a- cctg: reduced short-term variability CTG ABNORMAL Systolic cardiac failure
42 FETAL DETERIORATION IN PLACENTAL INSUFFICIENCY PLACENTAL DISEASE COMPENSATED HYPOXIA DECOMPENSATED HYPOXIA SERIOUS INJURY DEATH Increment placental impedance UTERINE A. >p95 CPR <p5 UMBILICAL A. >p95 Centralization MIDDLE CEREBRAL A. <p5 Ao ISTHMUS >p95 cardiac ischemia Diastolic failure growth DUCTUS VENOSUS >p95 and a- cctg: reduced short-term variability CTG ABNORMAL Systolic cardiac failure
43 FETAL DETERIORATION IN PLACENTAL INSUFFICIENCY EARLY VS LATE IUGR (>34s) PLACENTAL DISEASE COMPENSATED HYPOXIA DECOMPENSATED HYPOXIA SERIOUS INJURY DEATH Increment placental impedance CPR <p5 UMBILICAL A. >p95 Centralization MIDDLE CEREBRAL A. <p5 cardiac ischemia Diastolic failure growth DUCTUS VENOSUS >p95 and a- CTG / BPP ABNORMAL Systolic cardiac failure
44 FETAL DETERIORATION IN PLACENTAL INSUFFICIENCY EARLY VS LATE IUGR (>34s) PLACENTAL DISEASE COMPENSATED HYPOXIA DECOMPENSATED HYPOXIA SERIOUS INJURY DEATH Increment placental impedance Placental injury <30% CPR <p5 UMBILICAL A. >p95 Centralization MIDDLE CEREBRAL A. <p5 cardiac ischemia Diastolic failure growth DUCTUS VENOSUS >p95 and a- CTG / BPP ABNORMAL Systolic cardiac failure
45 FETAL DETERIORATION IN PLACENTAL INSUFFICIENCY EARLY VS LATE IUGR (>34s) PLACENTAL DISEASE COMPENSATED HYPOXIA DECOMPENSATED HYPOXIA SERIOUS INJURY DEATH Increment placental impedance Placental injury <30% CPR <p5 UMBILICAL A. >p95 Centralization MIDDLE CEREBRAL A. <p5 cardiac ischemia Diastolic failure growth DUCTUS VENOSUS >p95 and a- CTG / BPP ABNORMAL Systolic cardiac failure
46 FETAL DETERIORATION IN PLACENTAL INSUFFICIENCY EARLY VS LATE IUGR (>34s) PLACENTAL DISEASE COMPENSATED HYPOXIA DECOMPENSATED HYPOXIA SERIOUS INJURY DEATH Increment placental impedance Placental injury <30% CPR <p5 UMBILICAL A. >p95 Centralization MIDDLE CEREBRAL A. <p5 cardiac ischemia Diastolic failure growth DUCTUS VENOSUS >p95 and a- CTG / BPP ABNORMAL mild hypoxia no cardiovascular adaptation Systolic cardiac failure
47 FETAL DETERIORATION IN PLACENTAL INSUFFICIENCY EARLY VS LATE IUGR (>34s) PLACENTAL DISEASE COMPENSATED HYPOXIA DECOMPENSATED HYPOXIA SERIOUS INJURY DEATH Increment placental impedance Placental injury <30% CPR <p5 UMBILICAL A. >p95 Centralization MIDDLE CEREBRAL A. <p5 growth CTG / BPP ABNORMAL mild hypoxia no cardiovascular adaptation
48 FETAL DETERIORATION IN PLACENTAL INSUFFICIENCY EARLY VS LATE IUGR (>34s) PLACENTAL DISEASE COMPENSATED HYPOXIA DECOMPENSATED HYPOXIA SERIOUS INJURY DEATH Increment placental minimal tolerance to hypoxia impedance Placental injury <30% CPR <p5 UMBILICAL A. >p95 Centralization MIDDLE CEREBRAL A. <p5 growth CTG / BPP ABNORMAL mild hypoxia no cardiovascular adaptation
49 FETAL DETERIORATION IN PLACENTAL INSUFFICIENCY EARLY VS LATE IUGR (>34s) PLACENTAL DISEASE DECOMPENSATED HYPOXIA SERIOUS INJURY DEATH Increment placental minimal tolerance to hypoxia impedance Placental injury <30% CPR <p5 UMBILICAL A. >p95 Centralization MIDDLE CEREBRAL A. <p5 growth CTG / BPP ABNORMAL mild hypoxia no cardiovascular adaptation
50 FETAL DETERIORATION IN PLACENTAL INSUFFICIENCY EARLY VS LATE IUGR (>34s) PLACENTAL DISEASE DECOMPENSATED HYPOXIA SERIOUS INJURY DEATH Increment placental minimal tolerance to hypoxia impedance UTERINE A. >p95 Placental injury <30% CPR <p5 UMBILICAL A. >p95 Centralization MIDDLE CEREBRAL A. <p5 growth CTG / BPP ABNORMAL mild hypoxia no cardiovascular adaptation
51 FETAL DETERIORATION IN PLACENTAL INSUFFICIENCY EARLY VS LATE IUGR (>34s) PLACENTAL DISEASE DECOMPENSATED HYPOXIA SERIOUS INJURY DEATH Increment placental minimal tolerance to hypoxia impedance UTERINE A. >p95 Placental injury <30% CPR <p5 UMBILICAL A. >p95 Centralization MIDDLE CEREBRAL A. <p5 Ao ISTHMUS >p95 growth CTG / BPP ABNORMAL mild hypoxia no cardiovascular adaptation
52 IUGR= low CPR or high UtA or EFW<p3 or low PlGF 6 % SGA? 3 IUGR EARLY IUGR (1%) LATE IUGR (5-7%) PROBLEM: MANAGEMENT Placental disease: high (UA+, PE high) Hypoxia ++: systemic CV adaptation Tolerance to hypoxia. Natural history High mortality and morbidity PROBLEM: DIAGNOSIS Placental disease: low (UA-, PE low) Hypoxia +/-: central CV adaptation Low tolerance: no natural history Low mortality but poor long outcome.
53 1. Identify small fetus 2. FGR vs. SGA 3. Early vs. Late 4. Stage-based management protocol
54 IUGR = abnormal CPR or UtA or EFW<p3 Savchev 2013
55 IUGR = abnormal CPR or UtA or EFW<p3 Savchev 2013
56 IUGR = abnormal CPR or UtA or EFW<p3 Savchev 2013
57 IUGR = abnormal CPR or UtA or EFW<p3 Savchev 2013
58 IUGR = abnormal CPR or UtA or EFW<p3 Savchev 2013
59 RATIONALE FOR A STAGE-BASED APPROACH TO THE MANAGEMENT OF FGR PLACENTAL DISEASE HYPOXIA ACIDOSIS SERIOUS INJURY DEATH Increment placental impedance Centralization cardiac Diastoli Stage fetal deterioration II III IV V Systolic cardiac failure Risks of prematurity LOW MODERATE HIGH Red Line LATE IUGR Red Line EARLY IUGR
60 RATIONALE FOR A STAGE-BASED APPROACH TO THE MANAGEMENT OF FGR PLACENTAL DISEASE HYPOXIA ACIDOSIS SERIOUS INJURY DEATH Increment placental impedance Centralization cardiac Diastoli cctg: reduced STV Stage fetal deterioration II III IV V Systolic cardiac failure Risks of prematurity LOW MODERATE HIGH Red Line LATE IUGR Red Line EARLY IUGR
61 RATIONALE FOR A STAGE-BASED APPROACH TO THE MANAGEMENT OF FGR PLACENTAL DISEASE HYPOXIA ACIDOSIS SERIOUS INJURY DEATH Diagnostic/chronic markers Early and Late IUGR Increment placental impedance Centralization cardiac Diastoli cctg: reduced STV Stage fetal deterioration II III IV V Systolic cardiac failure Risks of prematurity LOW MODERATE HIGH Red Line LATE IUGR Red Line EARLY IUGR
62 RATIONALE FOR A STAGE-BASED APPROACH TO THE MANAGEMENT OF FGR PLACENTAL DISEASE HYPOXIA ACIDOSIS SERIOUS INJURY DEATH Diagnostic/chronic markers Early and Late IUGR Increment placental impedance Prognostic/Acute markers Early IUGR Centralization cardiac Diastoli cctg: reduced STV Stage fetal deterioration II III IV V Systolic cardiac failure Risks of prematurity LOW MODERATE HIGH Red Line LATE IUGR Red Line EARLY IUGR
63 Protocolo CIR Primer paso: si todo N = PEG I Doppler normal pero PFE<p3 II Aumento resistencia placentaria o redistribución inicial III Aumento grave resistencia y/o redistribución grave IV Alteración hemodinámica grave V Alto riesgo de muerte
64 Protocolo CIR Primer paso: si todo N = PEG I Doppler normal pero PFE<p3 II Aumento resistencia placentaria o redistribución inicial CPR <p5 Ut A >p95 MCA <p5 III Aumento grave resistencia y/o redistribución grave IV Alteración hemodinámica grave V Alto riesgo de muerte
65 Protocolo CIR Primer paso: si todo N = PEG I Doppler normal pero PFE<p3 II Aumento resistencia placentaria o redistribución inicial CPR <p5 Ut A >p95 MCA <p5 III Aumento grave resistencia y/o redistribución grave AEDV AoI >p95 IV Alteración hemodinámica grave V Alto riesgo de muerte
66 Protocolo CIR Primer paso: si todo N = PEG I Doppler normal pero PFE<p3 II Aumento resistencia placentaria o redistribución inicial CPR <p5 Ut A >p95 MCA <p5 III Aumento grave resistencia y/o redistribución grave AEDV AoI >p95 IV Alteración hemodinámica grave DV >p95 REDV UVpuls V Alto riesgo de muerte
67 Protocolo CIR Primer paso: si todo N = PEG I Doppler normal pero PFE<p3 II Aumento resistencia placentaria o redistribución inicial CPR <p5 Ut A >p95 MCA <p5 III Aumento grave resistencia y/o redistribución grave AEDV AoI >p95 IV Alteración hemodinámica grave DV >p95 REDV UVpuls V Alto riesgo de muerte DV (a rev) CGT decelerations of reduced short-term variability
68 IUGR Management protocol according to severity stages Stage V IV III II I Follow- up Daily 1-2 d 2/w 1/w Delivery DV(a- ) cctg abn. CTG dec. DV>p95 UV puls REDV (a) AEDV (b) AoI>95 Mode CS CS CS or LI LI EFW<p3 CPR>p95 UtA>p95 MCA<p5 <26w Mort. >90% 50% <10% Morb. >90% 50%
69 IUGR Management protocol according to severity stages Stage V IV III II I Follow- up Daily 1-2 d 2/w 1/w Delivery DV(a- ) cctg abn. CTG dec. DV>p95 UV puls REDV (a) AEDV (b) AoI>95 Mode CS CS CS or LI LI EFW<p3 CPR>p95 UtA>p95 MCA<p5 <26w Mort. >90% 50% <10% Morb. >90% 50%
70 IUGR Management protocol according to severity stages Stage V IV III II I Follow- up Daily 1-2 d 2/w 1/w Delivery DV(a- ) cctg abn. CTG dec. DV>p95 UV puls REDV (a) AEDV (b) AoI>95 Mode CS CS CS or LI LI EFW<p3 CPR>p95 UtA>p95 MCA<p5 <26w Mort. >90% 50% <10% Morb. >90% 50%
71 IUGR Management protocol according to severity stages Stage V IV III II I Follow- up Daily 1-2 d 2/w 1/w Delivery DV(a- ) cctg abn. CTG dec. DV>p95 UV puls REDV (a) AEDV (b) AoI>95 Mode CS CS CS or LI LI EFW<p3 CPR>p95 UtA>p95 MCA<p5 <26w Mort. >90% 50% <10% Morb. >90% 50%
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73 The main goal in FGR is identification
74 The main goal in FGR is identification Small fetus (EFW<p10) must be divided in:
75 The main goal in FGR is identification Small fetus (EFW<p10) must be divided in: FGR (placenta, poor perinatal and long-term outcome)
76 The main goal in FGR is identification Small fetus (EFW<p10) must be divided in: FGR (placenta, poor perinatal and long-term outcome) SGA (we don t know, perinatal outcome N, poor long term)
77 The main goal in FGR is identification Small fetus (EFW<p10) must be divided in: FGR (placenta, poor perinatal and long-term outcome) SGA (we don t know, perinatal outcome N, poor long term) Early and late-onset FGR (GA 32s) represent two distinct phenotypes of the same disease
78 The main goal in FGR is identification Small fetus (EFW<p10) must be divided in: FGR (placenta, poor perinatal and long-term outcome) SGA (we don t know, perinatal outcome N, poor long term) Early and late-onset FGR (GA 32s) represent two distinct phenotypes of the same disease Clinically, a single stage-based protocol allows optimizing decisions in all cases
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