ACTUALIZACIîN EN CRECIMIENTO INTRAUTERINO RESTRINGIDO

Eduard Gratacós

www.fetalmedicinebarcelona.org/

ACTUALIZACIÓN EN CRECIMIENTO INTRAUTERINO RESTRINGIDO

BCNatal – Barcelona Center of Maternal-Fetal and Neonatal MedicineHospital Clínic and Hospital Sant Joan de Déu, Universitat de Barcelona


http://www.fetalmedicinebarcelona.org




www.medicinafetalbarcelona.org/

0%

10%

20%

30%

40%

50%

FGR Unknown Others

25%

30%

45%

“SMALL FETUSES” AND MORTALITY AT TERM

Gardosi 2005 and 2013 Figueras 2012




Lindquist and Molin, 2005

n = 26 968

Gardosi et al. BMJ 2005 and 2013

Overall stillbirth / 1000 births: 2.4 in non-SGA vs19.8 in not detected SGA




Placental insufficiency = high risk of IUFD and fetal/neonatal acidosis

10

50

Feta

l wei

ght c

entil

e

“Small fetuses”

Placental “respiratory” smallness = risk distress + IUFD

Non-“respiratory” smallness = no distress/IUFD risk

0Risk of placental insufficiency

100

Fetal Smallness = higher risk of placental

insufficiency




1. Identificación del feto “pequeño”

2. Distinguir insuficiencia placentaria (CIR vs PEG)

3. Determinar seguimiento y parto




Neonatal vs Fetal GA “normal” weight in the same population



Mula 2013, Lobmaier 2013, Khalil 2014, Nicolaides 2015www.fetalmedicinebarcelona.org/

IMPROVING DETECTION & DEFINITION OF “RESTRICTION”Birthweight inverse relation with perinatal outcome AND brain-cardiac remodelling

RESE

ARCH



www.medicinafetalbarcelona.org

5-15% during 3rd trimester

30% perinatal complications; 10-15% term stillbirth

decrease2of2fetal2movements

25% IUGR

4% preterm delivery

1% stillbirth

70% Normal

stillbirth reduction OR 0.36

increase IUGR detection(IUGR > 36 w not diagnosed before)


Neonatal vs Fetal GA “normal” weight in the same population




Placental insufficiency = high risk of IUFD and fetal/neonatal acidosis

10

50

Feta

l wei

ght c

entil

e

“Small fetuses”

Placental “respiratory” smallness = risk distress + IUFD

Non-“respiratory” smallness = no distress/IUFD risk

0Risk of placental insufficiency

100

Fetal Smallness = higher risk of placental

insufficiency




SGA Unknown (constitutional + others)

FGRPlacental insufficiency

ISOLATED FETAL SMALLNESS (= POORER PROGNOSIS)Perinatal and Long-term Outcomes

Exclude extrinsic cause

Exclude primary fetal defect

Poor perinatal outcome + IUFD(Doppler) Signs of adaptation

Perinatal outcome normal - No IUFDNO signs of adaptation

FGR vs. SGA: DIFFERENT MANAGEMENT




Constitutionally small Placental insufficiency Extrinsic cause

Primary fetal defect

SGA FGR

The discovery of UA and hemodynamics of FGR

FGR = abnormal UA Doppler

20 30 4025 35

0

N2cases

N2cases

UA Doppler +(EARLY-ONSET)

UA Doppler N(LATE-ONSET)

Savchev22013




0

10

20

30

40

Neonatal acidosis CS for distress Abnormal NBAS Any

%

Figueras 2011

Evidence #1: SGA + NORMAL UA DOPPLER = POORER OUTCOMES

(n= 376)


NON-DETECTED IUGR AND TERM

MORTALITYBarcelona

2005-2014

0%

10%

20%

30%

40%

50%

FGR Unknown Others

25%30%

45%

Stillbirth by relevant condition at birth (ReCoDe)Gardosi et al. BMJ 2005 and 2013

IUGR as relevant condition identified in 43-60%Overall stillbirth / 1000 births: 2.4 in non-SGA VS. 19.8 in not detected SGA

Evidence #2: “SGA” HAVE HIGHER RISK OF IUFD AT TERM




CIR = ¿Doppler AU anormal?

20 30 4025 35

0

N2cases

N2cases

UA Doppler +(EARLY-ONSET)

UA Doppler N(LATE-ONSET)

Savchev22013

Ya no

.



Risk of CS for distress and/or neonatal acidosis

N=509 SGA + 509 controls


UtA >p95

CPR <p5

EFW CENTILE <3

0%

10%

20%

30%

40%

50%

8%11%

40%

Controls All normal Any abnormal

%

Prognostic criteria for poor outcome among small fetuses with normal UA Doppler

Figueras 2012



IPUA=p80

Cerebroplacental ratio is more sensitive than UA or MCA alone

CPR <p5

IPMCA=p20

=+


UtA >p95

CPR <p5 EFW CENTILE <3

Figueras 2012

CIR = PFE <p10 + cualquiera de




Distribution of cases when FGR = abnormal UA Doppler

Savchev 2013




Distribution of cases when FGR = abnormal CPR or UtA or EFW<p3

Savchev 2013




SGA Unknown (constitutional + others)

FGRPlacental insufficiency

ISOLATED FETAL SMALLNESS = POORER PROGNOSISPerinatal and Long-term Outcomes

Exclude extrinsic cause

Exclude primary fetal defect

Poor perinatal outcome + IUFD(Doppler) Signs of adaptation

Perinatal outcome normal - No IUFDNO signs of adaptation

FGR vs. SGA: DIFFERENT MANAGEMENT



Early-severeHigh risk IUFD preterm

PROBLEM: TIMING DELIVERYQ: Delivery? Next exam?


FGR = abnormal CPR or UtA or EFW<p3

Management = when should we deliver?

Savchev 2013

Late-mildNo IUFD <37w (risk at term)

PROBLEM: DETECTIONQ: Is it FGR or SGA?




FGR = abnormal CPR or UtA or EFW<p3

Savchev 2013



deliver when risks are:


RATIONALE FOR AN INTEGRATED STAGE-BASED APPROACH TO THE MANAGEMENT OF FGR

PLACENTAL DISEASE HYPOXIA ACIDOSIS SERIOUS INJURY DEATH

cardiac ischemiaDiastolic failure

Systolic cardiac failure

Centralization

Increment placental impedance

cCTG: reduced STV

Diagnostic/chronic markersDIFFERENCE FGR VS SGA

Prognostic/Acute markersINDICATION ABOUT THE SHORT-TERM RISK

OF IUFD/BRAIN INJURY

IVIIIIIIStage fetal deterioration

HIGHMILDMINIMALRisks of prematurity

BPP < 4



VERY&HIGH HIGH MODERATE

Mort.&&&& >90%& 50%& <10%Morb.& & >90%& & 50%


<26w 26-28 28-30 30-34 34-37

FGRManagement protocol according to severity stages

Deliver'at Any&1me

Risk'of'IUFD/brain'injury

DV(a6),&cCTG,&CTG&dec

Stage IV

Mode CS

Follow=up Hours/Daily

30

DV>p95,&REDV

III

CS

162&d

34

AEDV,&AoI>95

II

CS&or&LI

2/w

37

EFW<p3,&CPR&<p5,&UtA>95

I

LI

1/w

LOW




Delivery

Stage 1




Primer objetivo:Identificación del feto “pequeño” (PFE<p10)

Segundo objetivo: Clasificar como CIR vs PEG con RCP, AUt y PFE<3.

Tercer objetivo: Decidir pauta seguimiento y momento del parto:

utilizar un protocolo integrado basado en estadíos.



ACTUALIZACIîN EN CRECIMIENTO INTRAUTERINO RESTRINGIDO

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