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MANAGEMENT OF
FETAL GROWTH RESTRICTION
Eduard Gratacos
Center for Maternal-Fetal Medicine and Neonatology
Hospital Clinic & Hospital Sant Joan de Deu - University de Barcelona
www.fetalmedicinebarcelona.org
www.fetalmedicinebarcelona.org/
Neonatal and Fetal GA-adjusted “normal”
weight in the same population
www.medicinafetalbarcelona.org/
Exclude primary fetal defect
IUGR SGA
Placental insufficiency Unknown (constitutional + others)
www.medicinafetalbarcelona.org/
Prognostic criteria of “poor outcome”-SGA
CS for distress and/or neonatal acidosis
UtA CPR
<p5 EFW CENTILE <3
>p95
(<p15)
50%
N=509 SGA + 509 controls 40%
40%
30%
%
20%
11%
10% 8%
0%
Controls All normal Any abnormal
www.medicinafetalbarcelona.org/ Figueras 2013
IUGR = abnormal CPR or UtA or EFW<p3
early vs late-onset IUGR
Savchev 2013
www.medicinafetalbarcelona.org/
RATIONALE FOR A STAGE-BASED APPROACH TO THE
MANAGEMENT OF FGR
cardiac
Diastoli
Centralization
Systolic cardiac
Stage fetal
deterioration I II III IV failure
Risks of
prematurity LOW MODERATE HIGH
www.medicinafetalbarcelona.org/
1. Identify small fetus
www.medicinafetalbarcelona.org/
1. Identify small fetus
Return
www.medicinafetalbarcelona.org/
Neonatal and Fetal GA-adjusted “normal”
weight in the same population
www.medicinafetalbarcelona.org/
IMPROVING DETECTION: THE DEFINITION OF “RESTRICTION”
Birthweight inverse relation with perinatal outcome AND brain-cardiac remodelling
Return
www.medicinafetalbarcelona.org/
Exclude primary fetal defect
IUGR SGA
Placental insufficiency Unknown (constitutional + others)
www.medicinafetalbarcelona.org/
The discovery of UA and hemodynamics of IUGR
Constitutionally small Placental insufficiency Extrinsic cause
Primary fetal
defect
SGA FGR
N cases
UA Doppler +
(EARLY-ONSET)
UA Doppler N
(LATE-ONSET)
N
cases
Savchev
2013
20 25 30 35 40
www.medicinafetalbarcelona.org/
SGA: proportion of perinatal adverse
outcomes in 376 consecutive cases
40
30
%
20
10
0
Neonatal acidosis CS for distress Abnormal NBAS Any
Figueras 2011
www.medicinafetalbarcelona.org/
50% 45%
40%
IMPACT OF NON-DETECTED IUGR ON
30%
LATE FETAL MORTALITY 30% 25%
Barcelona
20%
2005-2010
10%
0%
FGR Unknown Others
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.
www.medicinafetalbarcelona.org/
Prognostic criteria of “poor outcome”-SGA
CS for distress and/or neonatal acidosis
UtA CPR
<p5 EFW CENTILE <3
>p95
50%
N=509 SGA + 509 controls 40%
40%
30%
%
20%
11%
10% 8%
0%
Controls All normal Any abnormal
www.medicinafetalbarcelona.org/ Figueras 2012
Distribution of cases when IUGR = abnormal UA Doppler
Savchev 2013
www.medicinafetalbarcelona.org/
Distribution of cases when IUGR = abnormal CPR or UtA or EFW<p3
Savchev 2013
www.medicinafetalbarcelona.org/
1. Identify small fetus
Return
www.medicinafetalbarcelona.org/
IUGR= low CPR or high UtA or EFW<p3 or low PlGF
6 %
SGA?
3
IUGR
0
20 25 30 35 40
32w @diagnosis
Placental disease: high (UA+, PE high) Placental disease: low (UA-, PE low)
High mortality and morbidity Low mortality but poor long outcome.
www.fetalmedicinebarcelona.org/
FETAL DETERIORATION IN PLACENTAL INSUFFICIENCY
Increment placental
impedance
UTERINE A. >p95
Centralization
cardiac ischemia
Diastolic failure
Systolic cardiac
failure
www.medicinafetalbarcelona.org/
FETAL DETERIORATION IN PLACENTAL INSUFFICIENCY
EARLY VS LATE IUGR (>34s)
Centralization
cardiac ischemia
Diastolic failure
mild hypoxia
no cardiovascular adaptation Systolic cardiac
failure
www.medicinafetalbarcelona.org/
IUGR= low CPR or high UtA or EFW<p3 or low PlGF
6 %
SGA?
3
IUGR
0
20 25 30 35 40
32w @diagnosis
Placental disease: high (UA+, PE high) Placental disease: low (UA-, PE low)
High mortality and morbidity Low mortality but poor long outcome.
www.fetalmedicinebarcelona.org/
1. Identify small fetus
Return
www.medicinafetalbarcelona.org/
S D
umbilical artery
normal and anormal
hemodynamics
Placental status
<30%
Cardiac pump
normal function
Cardiac pump
abnormal function
middle cerebral artery
normal and abnormal
hemodynamics
Normal oxygenation
[normal waveform]
[mild vasodilation]
[marked vasodilation]
hypoxia
30 % venous return
REFLECTS DIASTOLIC PRESSURE IN
RIGHT (AND LEFT) HEART
www.medicinafetalbarcelona.org/
ductus venosus
normal and abnormal
hemodynamics
S D
A
compliance right
chambers: effect sobre P
on venous return
no
Myocardial
ischemia
P
compliance
P
Early-onset IUGR
PROBLEM #1: MORTALITY
cCTG-‐STV<3 ms
Pathological
CGT
60%
DVa
(rev)
19%
Yes No
Baschat
2003
Hecher
2003
Grivell
2009
www.medicinafetalbarcelona.org/ Cruz-‐Lemini
2012
Early-onset IUGR
PROBLEM #2: (NEUROLOGICAL) MORBIDITY
Brain US anomalies in 30w IUGR
Controls Controls
IUGR antegrade AoI IUGR DV<5 z-score
IUGR retrograde AoI IUGR DV>5 z-score
60
*
*
45
(%)
30
15
Return
www.medicinafetalbarcelona.org/
IUGR = abnormal CPR or UtA or EFW<p3
Savchev 2013
www.medicinafetalbarcelona.org/
RATIONALE FOR A STAGE-BASED APPROACH TO THE
MANAGEMENT OF FGR
cardiac
Diastoli
Centralization
Systolic cardiac
Stage fetal
deterioration I II III IV failure
Risks of
prematurity LOW MODERATE HIGH
www.medicinafetalbarcelona.org/
Protocol IUGR
First step: UtA + CPR + EFW = SGA or IUGR
CPR Ut A MCA
I low EFW (<p3) or mild placental
resistance / redistribution <p5 >p95 <p5
DV >p95 REDV
III Severe hemodynamic adaptation
- Low suspicion acidosis
www.medicinafetalbarcelona.org/
IUGR
Management protocol according to severity stages
Stage IV III II I
DV>p95 EFW<p3
DV(a-‐) (a)
AEDV
Criteria UV
puls
(b)
AoI>95 CPR>p95
cCTG
abn.
REDV UtA>p95
CTG
dec.
MCA<p5
Delivery Any
Ome 30 34 37
www.medicinafetalbarcelona.org/
The main goal in FGR is identification
www.medicinafetalbarcelona.org/