39 th Annual Perinatal Conference Vanderbilt University December 6, 2013 IUGR. Diagnosis and Management

Transcription

1 39 th Annual Perinatal Conference Vanderbilt University December 6, 2013 IUGR Diagnosis and Management Giancarlo Mari, M.D., M.B.A. Professor and Chair Department of Obstetrics and Gynecology University of Tennessee Health Science Center Memphis, TN USA

2 At the end of this presentation the participants will be able: To classify IUGR fetuses To understand the cardiovascular changes that occur in IUGR fetuses To understand the issues in the management of IUGR fetuses

3 IUGR

4 Pubmed: IUGR 15,000 papers

5 IUGR-Definition Memphis Nashville Sidney

6 IUGR Fetus who fails to reach its growth potential

7 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)

8 IUGR Definitions: Each fetus is its own control (Deter-Rossavik) Ponderal index (Pediatricians) Population growth curves (Gardosi)

9 Perinatal Mortality Perinatal mortality (/1000) > Birth weight (%) Modified from Manning F. Fetal Medicine, 1995;7:307

10 EFW < 10 th percentile Normal Pathologic 80%? 20%? IUGR

11 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

12 Placental Insufficiency It is not the cause of IUGR but is rather the consequence of a disease process that often we do not understand

13 Doppler in AGA and IUGR Fetuses

14 Doppler Indices

15 Fitzgerald was the first to obtain a Doppler signal in pregnancy in 1977 Umbilical Artery

16 Mari G et al Am J Obstet Gynecol 1992;166:1262

17 Umbilical Artery: High placental vascular resistance

18 Umbilical Artery Doppler and Placental Vascular Histology Giles WB, et al. Br J Obstet Gynecol 1985;92:31 Placental arteries / High Power Field Normal Abnormal Abnormal Umbilical Doppler Waveform

19 Umbilical Artery Doppler and Outcome Reduce perinatal death and unnecessary induction of labor in the preterm growth restricted fetus A meta-analysis use of Doppler ultrasonography reduced the odds of perinatal death by 38 percent (95% CI 15-55) Alfirevic Z et al Am J Obstet Gynecol 1995

20 Brain Circulation

21 MCA MCA Waveforms at at 24 weeks Weeks A = Normal B = Brain sparing effect

22 Utero-Placental Vessels Normal pregnancy Preeclamptic and/or IUGR pregnancy Khong TJ et al, Br J Obstet Gynaecol, 1986;93:1049

23 Uterine Artery A B Mari G. Am J Obstet Gynecol 2009;200:613

24 SGA fetuses with normal umbilical artery Uterine arteries Middle cerebral arteries Severi FM, et al. Ultrasound Obstet Gynecol 2002;19:225-8

25 Venous System

26 Umbilical Vein Quantitative assessment: Velocity Qualitative assessment: Pulsation

27 Ductus Venosus

28 Is Ductus venosus reversed flow an indication for delivery?

29 DV Transitional Phase DV RF 1 hour later Picconi J, et al. Am J Perinatol 2008; 25:

30 DV RF 21 days before IUFD DV RF 9 days before delivery

31 Ductus venosus at < 28 weeks and EFW < 1000 g Is the biophysical profile normal or abnormal? B A C Kaur et al. Am J Obstet Gynecol 2008;199:264

32 a. What is the SIA index and b. What does it indicate? a. Peak systolic velocity Isovolumetric relaxation + a-wave b. Myocardial function Picconi et al J Ultrasound Med 2008;27:1283

33 Picconi et al J Ultrasound Med 2008;27:1283

34 Time Interval Between Occurrence of Pathologic Findings and Delivery Idiopathic (Blue) Preeclampsia (Yellow) Mari G, et al. Pren Diagn :377-83

35 Percent Parameters Abnormal in the Two Groups Mari G, et al. Pren Diagn :377-83

36 Staging and Classification of IUGR Fetuses

37 IUGR Staging I UA, MCA, DV UA MCA II UA III DV Mari G et al. J Ultrasound Med 2007;26: Modified by J Samson (2011)

38 IUGR Staging Amniotic fluid index < 5 > 5 A A B

39 IUGR Classification EFW < 10 th percentile Abnormal UA PI Amniotic fluid index >5 cm No maternal-fetal pathology 25 weeks IUGR Stage IB idiopathic 25 weeks

40 IUGR Staging Mari G et al. J Ultrasound Med 2007;26:

41 IUGR Staging Mari G et al. J Ultrasound Med 2007;26:

42 When should IUGR fetuses be delivered?

43 IUGR Delivery? GRIT DIGITAT TRUFFLE

44 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

45 IUGR and Timing of delivery Doppler/NST/BPP Stage 0 IUGR Stage I IUGR Stage II IUGR Stage III IUGR

46 Infant Mortality Rates (per 1000 births) Source: TN Dept. of Health, Office of Policy, Planning and Assessment, Division of Health Statistics