UPDATE ON DIAGNOSIS AND MANAGEMENT OF FETAL GROWTH · PDF fileupdate on diagnosis and management of fetal growth restriction ... placental disease hypoxia acidosis serious injury death

www.fetalmedicinebarcelona.org/

UPDATE ON DIAGNOSIS AND MANAGEMENT OF

FETAL GROWTH RESTRICTIONEduard Gratacos

Center for Maternal-Fetal Medicine and NeonatologyHospital Clinic & Hospital Sant Joan de Deu - University de Barcelona

www.fetalmedicinebarcelona.org

http://www.fetalmedicinebarcelona.org


www.medicinafetalbarcelona.org/

Neonatal and Fetal GA-adjusted “normal” weight in the same population


SGA Unknown (constitutional + others)

IUGRPlacental 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


UtA >p95

CPR <p5(<p15)

EFW CENTILE <3

0%

10%

20%

30%

40%

50%

8%11%

40%

Controls All normal Any abnormal

%

Prognostic criteria of “poor outcome”-SGACS for distress and/or neonatal acidosis

N=509 SGA + 509 controls

Figueras 2013


IUGR = abnormal CPR or UtA or EFW<p3early vs late-onset IUGR

Savchev 2013

Red Line EARLY IUGRRed Line LATE IUGR


RATIONALE FOR A 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 markersEarly and Late IUGR

Prognostic/Acute markersEarly IUGR

IVIIIIIIStage fetal deterioration

HIGHMODERATELOWRisks of prematurity




1. Identify small fetus

2. FGR vs. SGA

3. Early vs. Late

4. Parameters for fetal follow-up

5. Stage-based management protocol



2. FGR vs. SGA

3. Early vs. Late

4. Parameters for fetal follow-up


Return


Neonatal and Fetal GA-adjusted “normal” weight in the same population

Mula 2013, Lobmaier 2013www.medicinafetalbarcelona.org/

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

!

INTEGRATED 3T SCREENING FOR LATE-PREGNANCY COMPLICATIONSLate-PE, Late-IUGR, Stillbirth



2. FGR vs. SGA

3. Early vs. Late


Return


SGA Unknown (constitutional + others)

IUGRPlacental 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


Constitutionally small Placental insufficiency Extrinsic cause

Primary fetal defect

SGA FGR

The discovery of UA and hemodynamics of IUGR

FGR = abnormal UA Doppler

20 30 4025 35

0

N cases

N cases

UA Doppler +(EARLY-ONSET)

UA Doppler N(LATE-ONSET)

Savchev 2013


0

10

20

30

40

Neonatal acidosis CS for distress Abnormal NBAS Any

%

Figueras 2011

SGA: proportion of perinatal adverse outcomes in 376 consecutive cases


IMPACT OF NON-DETECTED IUGR ON LATE FETAL MORTALITYBarcelona2005-2010

0%

10%

20%

30%

40%

50%

FGR Unknown Others

25%30%

45%

Classification of stillbirth by relevant condition at birth (ReCoDe): population-based cohort studyGardosi et al. BMJ 2005 and 2013

IUGR as relevant condition identified in 43-60%

Overall stillbirth rate (/ 1000 births) 4.2, but only 2.4 in non-SGA pregnancies, increasing to 9.7 with antenatally detected IUGR and 19.8 in not detected IUGR.




UtA >p95

CPR <p5 EFW CENTILE <3

0%

10%

20%

30%

40%

50%

8%11%

40%

Controls All normal Any abnormal

%

Prognostic criteria of “poor outcome”-SGACS for distress and/or neonatal acidosis

N=509 SGA + 509 controls

Figueras 2012


Distribution of cases when IUGR = abnormal UA Doppler

Savchev 2013


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

Savchev 2013



2. FGR vs. SGA

3. Early vs. Late


Return


IUGR

SGA?

20 30 4025 35

0

3

6 %

IUGR= low CPR or high UtA or EFW<p3 or low PlGF

EARLY IUGR (1%) LATE IUGR (5-7%)

PROBLEM: MANAGEMENT PROBLEM: DIAGNOSIS

Placental disease: high (UA+, PE high) Placental disease: low (UA-, PE low)

Hypoxia ++: systemic CV adaptation Hypoxia +/-: central CV adaptation

Tolerance to hypoxia. Natural history Low tolerance: no natural history

High mortality and morbidity Low mortality but poor long outcome.

32w @diagnosis




FETAL DETERIORATION IN PLACENTAL INSUFFICIENCY

PLACENTAL DISEASE COMPENSATED HYPOXIA DECOMPENSATED HYPOXIA SERIOUS INJURYDEATH



Centralization


growth

MIDDLE CEREBRAL A. <p5

CPR <p5

DUCTUS VENOSUS >p95 and a-

CTG ABNORMAL

UTERINE A. >p95

cCTG: reduced short-term variability

Ao ISTHMUS >p95

UMBILICAL A. >p95




FETAL DETERIORATION IN PLACENTAL INSUFFICIENCY EARLY VS LATE IUGR (>34s)

PLACENTAL DISEASE COMPENSATED HYPOXIA DECOMPENSATED HYPOXIA SERIOUS INJURYDEATH



growth

UMBILICAL A. >p95

DUCTUS VENOSUS >p95 and a-

CTG / BPP ABNORMAL

Placental injury <30%

mild hypoxiano cardiovascular adaptation

minimal tolerance to hypoxia

MIDDLE CEREBRAL A. <p5

CPR <p5

UTERINE A. >p95

Ao ISTHMUS >p95

Centralization



IUGR

SGA?

20 30 4025 35

0

3

6 %

IUGR= low CPR or high UtA or EFW<p3 or low PlGF

EARLY IUGR (1%) LATE IUGR (5-7%)

PROBLEM: MANAGEMENT PROBLEM: DIAGNOSIS

Placental disease: high (UA+, PE high) Placental disease: low (UA-, PE low)

Hypoxia ++: systemic CV adaptation Hypoxia +/-: central CV adaptation

Tolerance to hypoxia. Natural history Low tolerance: no natural history

High mortality and morbidity Low mortality but poor long outcome.

32w @diagnosis





2. FGR vs. SGA

3. Early vs. Late

4. Parameters for fetal follow up


Return

umbilical arterynormal and anormal hemodynamics

DS

Cardiac pump normal function

Cardiac pump abnormal function

Placental status

<30%

placenta + cardiac ischemia

middle cerebral arterynormal and abnormalhemodynamics

[marked vasodilation]

[normal waveform]

[mild vasodilation]

Normal oxygenation

hypoxia


30 % venous return

REFLECTS DIASTOLIC PRESSURE IN RIGHT (AND LEFT) HEART



ductus venosusnormal and abnormal hemodynamics

Venous vessel: pulsation due to retrograde pressure

S DA

ductus venosusnormal and abnormal hemodynamics

compliance right chambers: effect sobre

on venous return

DS A

P

P

P

P

Myocardial ischemia

compliance

no

Perinatal >90% 30-‐40% <10%Mortality


<26 26-28 >28

Baschat 2003Hecher 2003 Grivell 2009Cruz-‐Lemini 2012

Early-onset IUGRPROBLEM #1: MORTALITY

DVa (rev)

Yes No

60%

19%

cCTG-‐STV<3 ms

Pathological CGT



Perinatal >90% 30-‐40% <10%Mortality


<29 29-32 >32.0

Fouron 2004Del Rio 2008Cruz-‐MarOnez 2012

Early-onset IUGRPROBLEM #2: (NEUROLOGICAL) MORBIDITY

0

15

30

45

60

(%)

ControlsIUGR antegrade AoIIUGR retrograde AoI

ControlsIUGR DV<5 z-scoreIUGR DV>5 z-score

**

Brain US anomalies in 30w IUGR





2. FGR vs. SGA

3. Early vs. Late

4. Parameters for fetal follow up


Return


IUGR = abnormal CPR or UtA or EFW<p3

Savchev 2013

Red Line EARLY IUGRRed Line LATE IUGR


RATIONALE FOR A STAGE-BASED APPROACH TO THE MANAGEMENT OF FGR

PLACENTAL DISEASE HYPOXIA ACIDOSIS SERIOUS INJURY DEATH



Centralization


cCTG: reduced STV

Diagnostic/chronic markersEarly and Late IUGR

Prognostic/Acute markersEarly IUGR

IVIIIIIIStage fetal deterioration

HIGHMODERATELOWRisks of prematurity




Protocol IUGRFirst step: UtA + CPR + EFW = SGA or IUGR

CPR<p5

Ut A >p95

MCA<p5

DV (a rev)

CGT decelerations of reduced short-term

variability

REDV DV >p95

I low EFW (<p3) or mild placental resistance / redistribution

III Severe placental resistance / redistribution

III Severe hemodynamic adaptation - Low suspicion acidosis

IV High suspicion of acidosis - High risk of death

AEDV AoI >p95



Delivery Any Ome 30 34 37

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


<26w 26-28 28-32 32-34 34-37

CriteriaDV(a-‐)

cCTG abn.CTG dec.

DV>p95UV puls REDV

(a) AEDV(b) AoI>95 CPR>p95

UtA>p95MCA<p5

EFW<p3

Stage IV III II I

Mode CS CS CS or LI LI

IUGRManagement protocol according to severity stages

Follow-‐up Hours/Daily 1-‐2 d 2/w 1/w




The main goal in FGR is identification

Small fetus (EFW<p10) must be divided in: FGR (placenta, poor perinatal and long-term outcome)

SGA (we don’t know, perinatal outcome N, poor long term)

Early and late-onset FGR (GA 32s) represent two distinct phenotypes of the same disease

Clinically, a single stage-based protocol allows optimizing decisions in all cases

Documents

UPDATE ON DIAGNOSIS AND MANAGEMENT OF FETAL GROWTH · PDF fileupdate on diagnosis and management of fetal growth restriction ... placental disease hypoxia acidosis serious injury death