Diagnosis and Management of the Early Growth Restricted Fetus
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1 11 th Congress of Maternal Fetal Medicine and Perinatology Society of Turkey Diagnosis and Management of the Early Growth Restricted Fetus Giancarlo Mari, MD, MBA, FACOG, FAIUM Professor and Chair Department of Obstetrics and Gynecology University of Tennessee Health Science Center Memphis, TN AIUM
2 Disclosures No Relevant Financial Relationships
3 Objectives At the end of this presentation the participant will be able to: Classify IUGR fetuses Describe the cardiovascular changes that occur in early IUGR fetuses Describe the management of IUGR fetuses
4 IUGR 15,000 papers
5 IUGR-Definition Istanbul Memphis Rome
6 IUGR Definitions: EFW < 10 th percentile (USA) EFW < 5 th percentile (USA) EFW < 3 rd percentile (USA) EFW < 15 th percentile (USA) EFW > 2 SD below mean (Europe) AC (10 th 2.5 th percentile (Europe)
7 Perinatal Mortality Perinatal mortality (/1000) > Birth weight (%) Modified from Manning F. Fetal Medicine, 1995;7:307
8 EFW < 10 th percentile Normal Pathologic 80%? 20%? IUGR (abnl Doppler)
9 1) Gestational age 2) Causes 3) Vital weeks 4) Fetal Weight 5) When to use the umbilical artery Doppler? 6) When to use the MCA Doppler? 7) When to use the Ductus venosus Doppler? 8) Delivery Timing 9) Doppler changes in the Early IUGR 10) IUGR Protocol used in Memphis
10 #1 Gestational age
11 IUGR Classification Early Late (< 32 weeks) (> 32 weeks)
12 #2 Causes
13 Placental Insufficiency Umbrella that covers our ignorance in terms of etiology and pathogenesis of the utero-placental chronic dysfunction Assali, Eur J Obstet Gynecol Reprod Biol 1975;5:87-91
14 Placental Insufficiency It is not the cause of IUGR but is rather the consequence of a disease process that often we do not understand
15 Comparison IUGR Pneumonia Placental Insufficiency Fever?????????????? Virus/Bacteria/Other
16 IUGR Idiopathic and secondary to maternal or fetal conditions Mari G and Hanif F COG 2007;50:
17 IUGR Classification Idiopathic Chromosomal abnormalities Chronic Hypertension Preeclampsia Infections Diabetes Other
18 #3 Vital weeks
19 IUGR and Gestational Age at Delivery Between 25 and 29 weeks ( vital weeks ), for each week the IUGR fetus remains in utero the mortality decreases by 48% Mari G et al. J Ultrasound Med 2007; 26:555-59
20 #4 Fetal weight
21 Two years later 25+5 weeks 360 grams DOL# 1 DOL# 7
22 Doppler in IUGR Umbilical artery Middle cerebral artery Ductus venosus
23 Umbilical Artery Placental Arteries / High Power Field Normal Abnormal Giles WB, et al. Br J Obstet Gynecol 1985;92:31 A B In cases of high placental vascular resistance (see IUGR), the umbilical artery diastole decreases (A), it becomes absent (B), and in the most severe cases, there is reversed flow (C) C
24 #5 When to use the umbilical artery Doppler?
25 Do we need to use the UA Doppler as a screening test for IUGR? Randomized and quasi-randomized studies (Doppler vs no Doppler in normal pregnancies) Five trials (14,624 women) There is no conclusive evidence that the use of routine UA Doppler, or combination of UA and uterine artery Doppler in low-risk or unselected populations benefits either mother or baby Alfirevic Z. et al. Cochrane Database Sys Rev. 2015
26 Do we need to use the UA Doppler in high risk pregnancies? Alfirevic Z. and Neilson JP. Am K Obstet Gynecol 1995;172:1379 Alfirevic Z., et al. Cochrane Database Syst Rev 2013
27 Circle of Willis The most studied artery of the Circle of Willis is the middle cerebral artery (MCA) Am J Obstet Gynecol 1989;160:698
28 Middle Cerebral Artery 24 Weeks Gestation A = Normal B = Brain sparing Effect Am J Obstet Gynecol 1992;166:1262
29 MCA
30 #6 When to use the MCA Doppler?
31 Do we need to use the MCA Doppler or the MCA/UA in IUGR? It has not to be used as a screening test There is no data that shows that the MCA/UA ratio is better than the MCA PI in IUGR It can be used with the umbilical artery Doppler in fetuses suspected to be IUGR
32
33 S D E A a PIV = S a Tmax Hemodynamically, these phases (S, D, a) reflect the rapid chronologic change in pressure gradients between the umbilical vein and the right atrium.
34 Ductus Venosus
35 Ductus venosus
36 #7 When to use the Ductus venosus Doppler?
37 Do we need to use the DV Doppler in IUGR? It provides information on the severity of IUGR A randomized trial on the use of Doppler of the DV for timing IUGR delivery was not conclusive It has not to be used for timing the delivery of IUGR fetuses
38 #8 Delivery Timing
39 IUGR Delivery? GRIT (24-36 weeks) DIGITAT (>36 weeks) PORTO ( ) TRUFFLE (26-32 weeks)
40 Trial of Umbilical and Fetal FLow In Europe IUGR: AC <10 th % + abnl UAPI weeks gestation CTG (abnormal STV) DV (abnormal PI) DV (ARF a wave)
41 TRUFFLE Trial Primary Outcome Primary outcome: Survival w/o cerebral palsy or neurosensory impairment Bayley III developmental score of less than 85, at 2 years of age Lees et al. Lancet, 2015; 385:
42 TRUFFLE Trial Results Liveborn: 491 (98%) Discharged home: 463 (92%) No. neonatal morbidity: 345 (69%) Fetuses alive at 2 years: 461 (92%) Follow-up at 2 years: 402 (80%) Bayley III cognitive test: 356 (70%) No difference in short-term outcomes between the 3 groups No difference in neurodevelopment impairment between the 3 groups (however, less frequent in DV-ARF group) Lancet, 2015; 385:
43 #9 Doppler changes in the Idiopathic IUGR at < 30 weeks
44 Aortic isthmus
45 Tricuspid regurgitation
46 Tricuspid regurgitation
47 Vessels Abnormalities Preceding NRFT or Fetal Demise
48 Doppler changes in IUGR in pregnancies with and without preeclampsia Pren Diagn :377-83
49 Percent Parameters Abnormal in the Two Groups Idiopathic (Blue) Preeclampsia (Yellow) Pren Diagn :377-83
50 IUGR (EFW < 10 th percentile) Staging Stage I IUGR: Stage II IUGR: Stage III IUGR: Stage IV IUGR: Normal UA-MCA Abnormal UA-MCA PI UA-AREDV DV-AREDV AFI = Normal (N) Abnormal (A)
51 #10 IUGR Protocol used in Memphis
52
53 Conclusion No standard in the diagnosis and management of the IUGR fetus Specialized centers Protocol vs. individualized care
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