Post on 04-Jun-2018
IUGRDiagnosis and Management
39th Annual Perinatal ConferenceVanderbilt UniversityDecember 6, 2013
Giancarlo Mari, M.D., M.B.A.Professor and Chair
Department of Obstetrics and GynecologyUniversity of Tennessee Health Science Center
Memphis, TNUSA
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
•EFW < 10th percentile (USA) •EFW < 5th percentile (USA) •EFW < 3rd percentile (USA)•EFW < 15th percentile (USA) •EFW > 2 SD below mean (Europe)•AC 10th 2.5th percentile (Europe)
Definitions:IUGR
•Each fetus is its own control (Deter-Rossavik)
•Ponderal index (Pediatricians)
•Population growth curves (Gardosi)
Definitions:
IUGR
Modified from Manning F. Fetal Medicine, 1995;7:307
1
26
51
76
101
126
151
176
>10 10 9 8 7 6 5 4 3 2 1 0.5Birth weight (%)
Peri
nata
l mor
talit
y (/1
000)
Perinatal Mortality
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
Placental Insufficiency
It is not the cause of IUGR but is rather the consequence of a disease process that often we do not understand
7.5
1.5Normal Abnormal
Giles WB, et al. Br J Obstet Gynecol 1985;92:31
Plac
enta
l arte
ries
/ Hig
h Po
wer
Fie
ld
Umbilical Doppler Waveform
Normal Abnormal
Umbilical Artery Doppler and Placental Vascular Histology
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
Normal pregnancy Preeclamptic and/orIUGR pregnancy
Khong TJ et al, Br J Obstet Gynaecol, 1986;93:1049
Utero-Placental Vessels
SGA fetuses with normal umbilical artery
• Uterine arteries
• Middle cerebral arteries
Severi FM, et al. Ultrasound Obstet Gynecol 2002;19:225-8
Ductus venosus at < 28 weeks and EFW < 1000 g
Is the biophysical profile normal or abnormal?
A
B
C
Kaur et al. Am J Obstet Gynecol 2008;199:264
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
Time Interval Between Occurrence of Pathologic Findings and Delivery
Idiopathic (Blue)Preeclampsia (Yellow)
Mari G, et al. Pren Diagn 2008 28:377-83
IUGR Staging
Mari G et al. J Ultrasound Med 2007;26:1489-77Modified by J Samson (2011)
IUA
MCAII
UA IIIDV
UA, MCA, DV
IUGR Classification• EFW < 10th percentile
• Abnormal UA PI
• Amniotic fluid index >5 cm
• No maternal-fetal pathology
• 25 weeks
IUGR Stage IB idiopathic 25 weeks
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