DOPPLER DOPPLER ASSESSMENT OF ASSESSMENT OF INTRAUTERINE INTRAUTERINE

GROWTH GROWTH RESTRICTIONRESTRICTION

CASE REPORT

A 29yr old female patient, primi ,average GA 30 weeks , k/c/o pre-eclampsia with altered PIH profile and decreased fetal movements was referred to our department for doppler evaluation .The bilateral uterine arteries , umbilical artery and the middle cerebral artery were evaluated.

Right uterine artery waveform demonstrating low diastolic flow (RI 0.72,S/D 2.8) and an early diastolic notch

Left Uterine artery waveform demonstrating low diastolic flow (RI 0.79,S/D 3.3) and an early diastolic notch.

Reversed diastolic flow seen in the Umbilical artery (fetal end) with RI of 1.25 and S/D 4.1.This implies a fetus at risk of significant morbidity/mortality.

Umbilical artery (mid-cord) showing absent end diastolic flow.

Umbilical artery (placental end) showing absent end diastolic flow.

Spectral flow within the Middle Cerebral artery showing increased diastolic flow ( S/D 2.5) and Brain-sparing effect (RI 0.6 ) .

In severely growth restricted fetus the ductus-venosus will show reversal of flow during atrial systole and transmitted venous pulsation in the umbilical vein.

This was a case of severe growth This was a case of severe growth restricted fetus in k/c/o prerestricted fetus in k/c/o pre--eclampsiaeclampsia..

The pregnancy was later terminated and The pregnancy was later terminated and the baby was shifted to the neonatal the baby was shifted to the neonatal intensive care unit where she is being intensive care unit where she is being treated.treated.

IUGRIUGRDefinition:Definition:Birth weight < 10Birth weight < 10thth percentile for the GA.percentile for the GA.

Second most commonSecond most common cause of LBW cause of LBW infants.infants.

Increased risk of Increased risk of perinatalperinatal morbidity and morbidity and mortality.mortality.

INCIDENCEINCIDENCE

OVERALL INCIDENCE:OVERALL INCIDENCE:

22--8%8% in the western countries.in the western countries.

It is much It is much higherhigher (2(2--3 times) in the developing 3 times) in the developing countries.countries.

RISK FACTORSRISK FACTORS

MaternalMaternal--hypertension, renal hypertension, renal disease,anaemiadisease,anaemia..Placental insufficiency.Placental insufficiency.Multiple pregnancyMultiple pregnancyPrevious growth retarded baby.Previous growth retarded baby.

TYPES OF IUGRTYPES OF IUGR

Type 1Type 1: Time of onset: Time of onset-- Second trimester.Second trimester.

FormForm-- symmetrical with the whole of the body symmetrical with the whole of the body being affected.being affected.

CausesCauses-- Chromosomal anomalies, intrauterine Chromosomal anomalies, intrauterine infections.infections.

Type 2Type 2

Time of onsetTime of onset--Third trimester. Third trimester.

FormForm-- Asymmetric, with the trunk being Asymmetric, with the trunk being affected than the head.affected than the head.

Commoner formCommoner form, 70, 70--80% cases80% casesCausesCauses--Hypertension, Hypertension, UteroplacentalUteroplacental

insufficiency. insufficiency.

DIAGNOSISDIAGNOSISDefinitive diagnosis can only be made Definitive diagnosis can only be made after delivery when the weight of the baby after delivery when the weight of the baby and the gestational age are known.and the gestational age are known.

Prenatal diagnosis is difficult. It requires Prenatal diagnosis is difficult. It requires the obstetrician to be aware of the the obstetrician to be aware of the condition and screening patients with high condition and screening patients with high risk factors.risk factors.

DOPPLERDOPPLERUmbilical arteryUmbilical artery --Decreased end diastolic flow Decreased end diastolic flow and raised and raised dopplerdoppler indices . In more extreme indices . In more extreme cases the endcases the end--diastolic flow may be absent or diastolic flow may be absent or even reversed.even reversed.Uterine arteryUterine artery-- Impedance remains high with Impedance remains high with early diastolic notch.early diastolic notch.Middle cerebral arteryMiddle cerebral artery-- Brain sparing effect.Brain sparing effect.DuctusDuctus--venosusvenosus-- Reverse flow during Reverse flow during atrialatrialcontraction and transmitted venous pulsation in contraction and transmitted venous pulsation in the umbilical vein.the umbilical vein.

UMBILICAL ARTERY

UTERINE ARTERY

MIDDLE CEREBRAL ARTERY

DUCTUS VENOSUS

MANAGEMENT

It is probably reasonable for the clinicians to deliver all small for gestational age fetuses that present with absent /reversed end diastolic flow after 28 weeks.

TAKE HOME MESSAGE

Doppler assessment of pregnancy cannot be used in the diagnosis of IUGR, but it can be used to co-relate fetal compromise and assess the fetal well being.Once identified ,the IUGR fetus should undergo serial evaluation with both doppler study and biophysical testing.

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