1. IUGR, AFI, and Aneuploidy
IUGR Anomalies Poly Aneuploid
X %
X X %
X X 27 %
X X X 47 %

2. Doppler

4. IUGR: Maternal Doppler
Uterine artery:
S/D > 2.6 associated with IUGR, IUFD
Elevated resistance index and IUGR:
70.6% sensitive
33.3% PPV

5. IUGR: Fetal Dopplers Umbilical: Falling pulsatility index in head:
rising S/D ratio = increasing placental resistance
associated with fewer small arteries of tertiary placental villi
Falling pulsatility index in head:
indicates increased flow to brain
Venous Dopplers:
Cardiovascular performance

6. IUGR: Fetal Dopplers Study of 43 IUGR fetuses:
85% had S/D ratios > 95th percentile
decreased diastolic flow indicating high placental flow resistance
Trudinger et al., Br J Obstet Gynaecol 92:39, 1985

7. IUGR: Dopplers and Outcome
When umbilical S/D known:
lower PNM rates, fewer antenatal admissions, fewer inductions, fewer C/S
no improvement noted for low risk pregnancies
Divon & Ferber, Perinat Neonat Med 5:3, 2000

8. Absent/Reversed EDV Doppler

9. Absent/Reversed EDV Doppler
80% will have IUGR
36% PNM rate
REDV: >70% placental arteries obliterated
Mean time to delivery 7 days (0-49)
Management:
BMS, hospital bed rest, intensive monitoring, liberal delivery
venous Dopplers

11. MCA Doppler Technique
Obtain axial section of the brain, including the thalami and the CSP. Sweep lower.
The circle of Willis is visualized.
MCA of one side is examined close to its origin from the internal carotid artery.
The angle of insonance is kept as close as possible to 0 degrees.

12. MCA Doppler: Dual Uses Fetal circulatory redistribution Fetal anemia
Pulsatility index, S/D ratio
Fetal anemia
Peak systolic velocity

13. IUGR: Middle Cerebral Doppler
Normally demonstrates low diastolic flow
Increased diastolic flow:
possible early indicator of fetal hypoxemia (Gudmundsson, 1996)
Sign of cerebral redistribution with chronic hypoxemia (brain sparing effect) (Wladimiroff, 1986; Mari, 1992; Gramellini, 1992)

14. IUGR: Middle Cerebral Doppler
Normal MCA
Abnormal MCA

15. IUGR: Value of Doppler SGA fetuses with: Normal AFV Normal UmA S/D
Normal MCA Dopplers
>97% NPV for major negative perinatal sequellae
Fong et al., Radiology 213:681, 1999.

16. Fetal Venous Circulation

17. Central Venous Circulation
Doppler flow waveforms
Fetal venous system has characteristic pulsations which reflect CVP

18. Normal Venous DopplersDV UV

19. Abnormal Venous DopplersDV UV

20. IUGR: Venous Dopplers AEDV + umbilical vein pulsations = 54% mortality
Indik, Obstet Gynecol 77:551, 1991
Venous atrial back flow waves are suggestive of metabolic
Acidemia documented by PUBS
Hecher et al., Am J Obstet Gynecol 173:10, 1995

21. Fetal Diagn Ther. 2012;32(1-2):116-22

22. IUGR: Fetal Response to UPI
Respiratory/Metabolic Hypoxia and Acidosis
Dysfunction Hypercarbia
Compensation Decompensation
Shunting: High right atrial pressure
To: brain, heart, adrenal DV dilatation
From: lungs, bowel, kidney Myocardial dysfunction
Ultrasound/Doppler: Doppler:
Oligohydramnios venous/cardiac changes
UmA and MCA Dopplers BPP abnormal

23. IUGR: Fetal Well-Being
BPP use with IUGR:
strong association with cord pH
cascade of decompensation:
BPP: lower rates of intervention compared to OCT/CST, with equal outcomes
pH NR NST
No FBM
Movement
Tone Dead Man Float

24. Doppler Findings With BPP < 6
Baschat, Ultrasound Obstet Gynecol 18:571, 2001

25. Trends in Variables Before Delivery at <32 wksDV
BTBV
Hecher, Ultrasound Obstet Gynecol 18:564, 2001

26. IUGR: Therapy
Aspirin
ASA + dipyridamole from 16 weeks in women with Hx of IUGR
Treatment: 13% IUGR, no severe IUGR
No Tx: 61% IUGR, 27% server IUGR
Wallenburg, Am J Obstet Gynecol 157:1230, 1987
Meta-analysis on mg ASA
significant reduction of IUGR noted
Br J Obstet Gynecol 104:450, 1997

27. IUGR: Timing of Delivery
“The majority of fetal deaths occur after the 36th week
of gestation and before labor which leads to the conclusion that
many deaths could be prevented by accurate recognition of
growth restriction and appropriately timed and conducted
intervention.”
Frigoletto, Clin Obstet Gynecol, 1977

28. IUGR: Long Term Morbidity
The potential for normal long term growth is positive
late developing IUGR: excellent
early, prolonged IUGR: risk of suboptimal size (e.g. 50% with small HC have HC < 10th percentile at 8 years).

29. IUGR: Neurologic Outcome
Depends:
degree of IUGR, especially small HC
timing of onset
GA at delivery
postnatal care
CP risk is increased 4-6 times, for IUGR between weeks
Jarvis, Lancet Oct 4;362(9390):

30. IUGR: Adult Disease Barker Hypothesis
England/Wales , areas with high infant mortality correlated with CAD in men aged in the 1960s-70s
Theory: LBW survivors might have more CAD
Birth records:
BW < 5.5 lbs: 3 times number of deaths from CAD
HTN and CVA also increased
Greatest risk: LBW, small HC, short, small placentas
Also more: abdominal obesity, AODM, hyperlipidemia
Cause: pancreatic/adrenal insuff, sympath. dysfx?