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growth restriction
Dr Rebecca Spencer
Clinical Research Fellow
University College London
Outline
What is severe early onset IUGR?
How do we manage IUGR?
How can we cousel women?
What can we do about it?
IUGR is not the same as SGA
8% pregnancies
Contributes to
50% of stillbirths
Most due to
uteroplacental
insufficiency
Growth potential
Uteroplacental insufficiency
Trophoblast
invades the
spiral arteries
In IUGR there
is less
trophoblast
invasion
Non-pregnant IUGR Pregnant
Moffett-King A, 2002
Uteroplacental insufficiency
Human pregnancy
Uterine blood flow (ml/min)
%
survival
without
disability
Customised charts of
EFW may improve
detection and outcomes
Assess risk factors at booking
If major risk factors OR >2.0 then USS from 26-28/40 OR >2.0
If 3 or more minor risk factors then Ut Art Doppler at 20-24/40 Maternal age >40 yrs
Smoker or cocaine use
Previous SB or SGA
Potential Smoking cessation Maternal or paternal SGA
Heparin HT, APS, DM, renal failure
Interventions
Heavy APH
Echogenic bowel
Start antiplatelets <16/40 if risk factors for PET PET or severe PIH
May have benefit for preventing SGA Low PAPP-A (<0.4 MoM)
but not enough evidence yet Low maternal weight gain
Systematic reviews suggest RR for SGA neonate is Daily vigorous exercise
0.90 (0.83-0.98)
Patient pathway
If severe <23/40
Prediction: history, biomarkers, uterine artery Dopplers Identification of SGA
offer karyotype
Parental opinion
Degree of uteroplacental
insufficiency
Umbilical artery Dopplers
Soothill 1993 Meta-analysis Morris 2011
Raised umbilical Predicts SGA, wellbeing
artery PI predicts and outcome in high risk
hypoxic morbidity in
SGA < 2SD of mean
SGA <2.5th centile (n=7)
4.37
Absent or reversed a
Raised Umbilical artery PI wave
Odibo et al 2005
Ductus venosus
Ductus venosus
Turan et al, 2007
DV PI predicts fetal
DV-Reversed a wave acidosis at birth in
IUGR fetuses
Turan et al, 2011
Raised DV-PI Duration of absent/
reversed a-wave
Normal DV-PI predicts stillbirth
Ductus venosus
Intact survival
Baschat 2007
Gestational age
Survival <26+6 Neonatal mortality
Characterised three
patterns of Doppler changes
Ultrasound assessment in severe IUGR
Raised ductus venosus PI
Absent or reversed a
Raised Umbilical artery PI wave
Absent or reversed a
Raised Umbilical artery PI wave
Absent or reversed a
Raised Umbilical artery PI wave
24 34
<29+2 >32
30-32 If SGA with
<26+6 Gestation best
Consider delivery abnormal
Gestation predictor of intact
if umbilical AREDF umbilical artery
best survival
Doppler
predictor of
diagnosed
survival If abnormal DV or UV pulsations deliver after
>32/40 deliver
steroids if viable
by 37/40
Obvious abnormality
12
10
8
TOP
6
IUD / SB
4
Livebirth
2
0
18 - 19+6 20 - 21+6 22-23+6 24-25+6
44 31 developed PET
7 MTOP 9 IUD
livebirths
38 survived
6 NND (63%)
<10th centile
<500g
36 pregnancies UA AREDF
Median gestation 24 (18 - 29)
12 died in
5 survived to
delivery room or
discharge (14%)
NICU
What can we tell women with mid-trimester
uteroplacental IUGR?
Melatonin
Antioxidant and vasoactive
Neuroprotection in IUGR
Effects on fetal growth in rats and sheep
EVERREST
http://www.eur
am.ltd.uk/EVER
REST/index.html
#
Delivery of adenovirus containing
VEGF gene to uteroplacental
circulation
Local over-expression of VEGF