IUGR, AFI, and Aneuploidy IUGR Anomalies Poly Aneuploid X 7 % X X 32 % X X 27 % X X X 47 %

Doppler

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

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

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

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

Absent/Reversed EDV Doppler

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

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.

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

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)

IUGR: Middle Cerebral Doppler Normal MCA Abnormal MCA

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.

Fetal Venous Circulation

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

Normal Venous Dopplers DV UV

Abnormal Venous Dopplers DV UV

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

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

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

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

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

Trends in Variables Before Delivery at <32 wks DV BTBV Hecher, Ultrasound Obstet Gynecol 18:564, 2001

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 50-100 mg ASA significant reduction of IUGR noted Br J Obstet Gynecol 104:450, 1997

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

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).

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 32-42 weeks Jarvis, Lancet. 2003 Oct 4;362(9390):1106-11

IUGR: Adult Disease Barker Hypothesis England/Wales 1901-1910, areas with high infant mortality correlated with CAD in men aged 35-74 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?