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Current role of ultrasound in detection and management of pregnancies complicated by fetal growth restriction.

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Presentation on theme: "Current role of ultrasound in detection and management of pregnancies complicated by fetal growth restriction."— Presentation transcript:

1 Current role of ultrasound in detection and management of pregnancies complicated by fetal growth restriction

2 FGR : Magnitude of the problem * Perinatal mortality 120/1000 * 2 nd leading contributor to perinatal mortality rate * 40% of all stillbirths are IUGR

3 What is in a name ? Intrauterine growth retardation (IUGR) Intrauterine growth restriction (IUGR) Fetal growth restriction (FGR) Small for gestational age (SGA)

4 Definition : Fetal growth restriction * Ultrasound estimated fetal weight or abdominal circumference suboptimal for gestational age * FGR = FETAL diagnosis ( not neonatal ) * Defining threshold : < 10 th centile for gestational age < 5 th centile for gestational age (worse outcome)

5 Definition : Small for gestational age (SGA) * Birth weight suboptimal for gestational age * SGA = NEONATAL diagnosis (not fetal) * Defining threshold : < 10 th centile for gestational age Birth ratio : Actual birth weight / Expected birth weight

6 SMALL FETUS CHECK DATING OF THE PREGNANCY- PREVIOUS DATING SCAN EXAMINE FOR: -FETAL BIOMETRY -FETAL ABNORMALITIES/MARKERS -FETAL MOVEMENTS -AMNIOTIC FLUID INDEX -DOPPLERS -SYMMETRICALLY SMALL -NO ANOMALIES/ MARKERS -NORMAL ACTIVITY -NORMAL AMNIOTIC FLUID -NORMAL DOPPLERS WRONG DATES OR CONSTITUTIONALLY SMALL FETUS REPEAT SCAN IN 2-4 WEKS TO ENSURE LINEAR FETAL GROWTH ASSYMMETRICALLY SMALL -NO ANOMALIES / MARKERS -REDUCED ACTIVITY -REDUCED AMNIOTIC FLUID -ABNORMAL UTERINE OR FETOPLAC, DOPPLERS PLACENTAL INSUFFICIENCY SERIAL GROWTH SCANS AND DOPPLERS TO TIME DELIVERY -SYMMETRICALLY OR ASSYMMETRICALLY SMALL -FETAL ANOMALIES AND/OR ABNORMAL MARKERS -ACTIVITY NORMAL OR REDUCED -AMNIOTIC FLUID REDUCED, NORMAL OR INCREASED -UTERINE/FETOPLAC DOPPLER USUALLY NORMAL FETAL ABNORMALITY OFFER INVASIVVE ASSESSMENT CONGENITAL INFECTION SCREEN

7 SMALL FETUS CHECK DATING OF THE PREGNANCY- PREVIOUS DATING SCAN EXAMINE FOR: -FETAL BIOMETRY -FETAL ABNORMALITIES/MARKERS -FETAL MOVEMENTS -AMNIOTIC FLUID INDEX -DOPPLERS -SYMMETRICALLY SMALL -NO ANOMALIES/ MARKERS -NORMAL ACTIVITY -NORMAL AMNIOTIC FLUID -NORMAL DOPPLERS WRONG DATES OR CONSTITUTIONALLY SMALL FETUS REPEAT SCAN IN 2-4 WEKS TO ENSURE LINEAR FETAL GROWTH ASSYMMETRICALLY SMALL -NO ANOMALIES / MARKERS -REDUCED ACTIVITY -REDUCED AMNIOTIC FLUID -ABNORMAL UTERINE OR FETOPLAC, DOPPLERS PLACENTAL INSUFFICIENCY SERIAL GROWTH SCANS AND DOPPLERS TO TIME DELIVERY - SYMMETRICALLY OR ASSYMMETRICALLY SMALL -FETAL ANOMALIES AND/OR ABNORMAL MARKERS -ACTIVITY NORMAL OR REDUCED -AMNIOTIC FLUID REDUCED, NORMAL OR INCREASED -UTERINE/FETOPLAC DOPPLER USUALLY NORMAL FETAL ABNORMALITY OFFER INVASIVVE ASSESSMENT CONGENITAL INFECTION SCREEN

8 SMALL FETUS CHECK DATING OF THE PREGNANCY- PREVIOUS DATING SCAN EXAMINE FOR: -FETAL BIOMETRY -FETAL ABNORMALITIES/MARKERS -FETAL MOVEMENTS -AMNIOTIC FLUID INDEX -DOPPLERS - SYMMETRICALLY SMALL -NO ANOMALIES/ MARKERS -NORMAL ACTIVITY -NORMAL AMNIOTIC FLUID -NORMAL DOPPLERS WRONG DATES OR CONSTITUTIONALLY SMALL FETUS REPEAT SCAN IN 2-4 WEKS TO ENSURE LINEAR FETAL GROWTH ASSYMMETRICALLY SMALL -NO ANOMALIES / MARKERS -REDUCED ACTIVITY -REDUCED AMNIOTIC FLUID -ABNORMAL UTERINE OR FETOPLAC, DOPPLERS PLACENTAL INSUFFICIENCY SERIAL GROWTH SCANS AND DOPPLERS TO TIME DELIVERY - SYMMETRICALLY OR ASSYMMETRICALLY SMALL -FETAL ANOMALIES AND/OR ABNORMAL MARKERS -ACTIVITY NORMAL OR REDUCED -AMNIOTIC FLUID REDUCED, NORMAL OR INCREASED -UTERINE/FETOPLAC DOPPLER USUALLY NORMAL FETAL ABNORMALITY OFFER INVASIVVE ASSESSMENT CONGENITAL INFECTION SCREEN

9 I AM A FETUS IN THE WOMB I FEAR IT MAY BECOME MY TOMB IF ONLY I COULD GIVE A SHOUT TO MAKE MY DOCTOR GET ME OUT! UNKNOWN MEDICAL STUDENT DUBLIN, UK 1982

10 Dilemmas in FGR How to monitor When to deliver? cCTG Arterial Dopplers Venous Dopplers Biophysical profile

11 Dilemmas in management of FGR * Severe FGR due to placenta dysfunction - Progressive - No treatment to reverse the process * Timing of delivery - Risks : prematurity vs continued intrauterine life * Objective - Buy time to reduce prematurity risks, but deliver prior to organ damage * Question : Can this be accomplished ? * Answer : DOPPLER

12 Hecher K et al : Monitoring of fetuses with IUGR : a longitudinal study. UOG 2001; 18: Baschat AA et al: The sequence of changes in Doppler and BPP as severe FGR worsens. UOG 2001; 18: Ferrazzi E et al : Temporal sequence of abnormal Doppler changes in severe IUGR. UOG 2002; 19:

13 Phases of placental dysfunction causing FGR

14 Patterns of clinical progression in early FGR

15 STV and metabolic acidosis in IUGR STV (msec ) Gestation (wks ) – – 37 Metabolic acidosis * 10.3% 4.3% 2.7% IUFD 24.1% 4.3% 0.0% * pH 12 mmol/l Pardey J et al AJOG 2002; 186:

16 IUGR : DV, STV and perinatal mortality n alive IUFD NND Both abnormal /33 (39%) Both normal/or one abnormal /60 (7%) Total Hecher K et al, UOG 2001

17 Derks JB et al: The effects of maternal betamethasone administration on the fetus. BJOG 1995; 102:40-46 within 48 hours after initial betamethasone administration : * Reduction of fetal movements * Reduction of fetal breathing movements * Reduction of STV on NST All changes disappeared after 4 days following treatment

18 Thuring A et al: Effect of maternal betamethasone on fetal and uteroplacental blood flow.UOG 2011; 37: within 48 hours after initial betamethasone administration : * decreased UMA diastolic flow * decreased DV flow at time of atrial contraction * no changes of MCA and UTA flows All changes disappeared after 4 days following treatment

19 Patterns of clinical progression in late FGR

20 LATE-ONSET FGR AND NEURODEVELOPMENTAL DELAY Late-onset FGR > 34 wks Intracerebral Redistribution of Blood Flow Impaired -Performance attention -Communication -Problem solving -Emotions -Social function Basal ganglia Frontal Lobes MCAPI Neurodevelopmental delay Social- interactive attention Normal or UMAPI Early childhoodNeonatal period Cruz-Martinez R et al, AJOG 2009

21 Review of determinants of fetal neurodevelopment.

22 FGR monitoring – key points * UMA flow is useful parameter for assessment of high-risk population not a screening test * UMA flow unless it is severely abnormal does not tell us anything about fetal condition * MCA flow reflects the extent of fetal brain sparing=sign of arterial redistribution as fetal response to hypoxemia * One of drawbacks of existing fetal arterial redistribution is subsequent development of oligohydramnios *Computerized CTG is currently the best parameter to detect fetal acidosis by decreased STV ( < 3 msec) * Ductus venosus flow indirectly reflects the efficiency of the fetal heart and seems to correlate with the presence or absence of metabolic acidosis * Longitudinal monitoring ( at least 3 detailed studies) facilitates definition of trends of evaluated parameters in FGR. Different fetuses are showing different responses to impaired placental function i.e. all fetuses should be used as their own control

23 FGR delivery timing – key points * As IUGR fetus decompensates there are progressive Doppler velocimetry changes * These Doppler changes usually tend to follow a consistent pattern and largely occur prior to abnormalities in BPP. * Abnormal DVPI and STV values are important indicators for the optimal timing of delivery before 32wks of gestation * Metabolic acidosis, not necessarily hypoxia, correlates with neurological outcome in the infant * Gestational age overrides the effect of fetal cardiovascular condition until weeks * Neurodevelopment is affected by severely abnormal UMA and DV flows in early-onset FGR and by abnormal MCA flow in late-onset FGR

24 FGR MANAGEMENT PROTOCOL UMA Doppler Non-Reassuring NST Non-ReactiveNST Reactive weeks NST & Doppler studies UMA Doppler Reassuring Either Test Non-Reassuring Both Tests Reassuring weeks NST & Doppler studies Repeat in 1W Non-reassuring Deliver Reassuring Venous Doppler Repeat in 1W Deliver Callen 2010 BPP < 4 BPP 6 Repeat in 6-24 hours Deliver

25 LOOK TO THE FUTURE


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