docearly iugr - medicinafetalbarcelona
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early iugr - medicinafetalbarcelona
ACTUALIZACIÓN EN CRECIMIENTO INTRAUTERINO RESTRINGIDO Eduard Gratacos Servicio de Medicina Maternofetal Hospital Clinic y Hospital Sant Joan de Deu - Universidad de Barcelona www.fetalmedicinebarcelona.org www.fetalmedicinebarcelona.org/ 1. Identificar feto pequeño 2. CIR vs. PEG 3. Precoz vs. Tardío 4. Implicación en el manejo clínico www.medicinafetalbarcelona.org/ 1. Identificar feto pequeño 2. CIR vs. PEG 3. Precoz vs. Tardío 4. Implicación en el manejo clínico www.medicinafetalbarcelona.org/ Neonatal and Fetal GA-adjusted “normal” weight in the same population www.medicinafetalbarcelona.org/ Neonatal and Fetal GA-adjusted “normal” weight in the same population www.medicinafetalbarcelona.org/ 1. Identificar feto pequeño 2. CIR vs. PEG 3. Precoz vs. Tardío 4. Implicación en el manejo clínico www.medicinafetalbarcelona.org/ Savchev 2013 www.medicinafetalbarcelona.org/ The discovery of UA and hemodynamics of IUGR Savchev 2013 www.medicinafetalbarcelona.org/ The discovery of UA and hemodynamics of IUGR Constitutionally small Placental insufficiency Extrinsic cause Primary fetal defect IUGR = abnormal UA Doppler Savchev 2013 www.medicinafetalbarcelona.org/ The discovery of UA and hemodynamics of IUGR Constitutionally small Placental insufficiency Extrinsic cause Primary fetal defect SGA IUGR IUGR = abnormal UA Doppler Savchev 2013 www.medicinafetalbarcelona.org/ The discovery of UA and hemodynamics of IUGR Constitutionally small Placental insufficiency Extrinsic cause Primary fetal defect SGA IUGR IUGR = abnormal UA Doppler 20 25 30 35 www.medicinafetalbarcelona.org/ 40 Savchev 2013 The discovery of UA and hemodynamics of IUGR Constitutionally small Placental insufficiency Extrinsic cause Primary fetal defect SGA IUGR IUGR = abnormal UA Doppler N cases 0 N cases 20 25 30 35 www.medicinafetalbarcelona.org/ 40 Savchev 2013 The discovery of UA and hemodynamics of IUGR Constitutionally small Placental insufficiency Extrinsic cause Primary fetal defect SGA IUGR IUGR = abnormal UA Doppler N cases 0 N cases 20 25 30 35 www.medicinafetalbarcelona.org/ 40 Savchev 2013 The discovery of UA and hemodynamics of IUGR Constitutionally small Placental insufficiency Extrinsic cause Primary fetal defect SGA IUGR IUGR = abnormal UA Doppler N cases UA Doppler + (EARLY-ONSET) 0 N cases 20 25 30 35 www.medicinafetalbarcelona.org/ 40 Savchev 2013 The discovery of UA and hemodynamics of IUGR Constitutionally small Placental insufficiency Extrinsic cause Primary fetal defect SGA IUGR IUGR = abnormal UA Doppler N cases UA Doppler + (EARLY-ONSET) 0 UA Doppler N (LATE-ONSET) N cases 20 25 30 35 www.medicinafetalbarcelona.org/ 40 Savchev 2013 SGA = constitutionally small? SGA <p95 e www.medicinafetalbarcelona.org/ SGA = constitutionally small? SGA Significant increase in the risk of adverse perinatal outcome Hershkovitz et al. Ultrasound Obstet Gynecol 2000 Severi et al. Ultrasound Obstet Gynecol 2002 Figueras et al . Eur J Obstet Gynecol Reprod Biol 2008 <p95 e www.medicinafetalbarcelona.org/ SGA = constitutionally small? SGA Significant increase in the risk of adverse perinatal outcome Hershkovitz et al. Ultrasound Obstet Gynecol 2000 Severi et al. Ultrasound Obstet Gynecol 2002 Figueras et al . Eur J Obstet Gynecol Reprod Biol 2008 <p95 e Significant increase in the risk of adverse neurodevelopment Eixarch et al. Ultrasound Obstet Gynecol 2008 Severi et al. Ultrasound Obstet Gynecol 2002 Figueras et al . Eur J Obstet Gynecol Reprod Biol 2008 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 www.medicinafetalbarcelona.org/ Any Figueras 2011 50% IMPACT OF NONDETECTED IUGR ON LATE FETAL MORTALITY Hospital Clínic Barcelona 2005-2010 45% 40% 30% 30% 25% 20% 10% 0% FGR Unknown Others Relevant Condition ReCoDe www.medicinafetalbarcelona.org/ 50% IMPACT OF NONDETECTED IUGR ON LATE FETAL MORTALITY Hospital Clínic Barcelona 2005-2010 45% 40% 30% 30% 25% 20% 10% 0% FGR Unknown Others Relevant Condition ReCoDe Impact of growth restriction in late pregnancy stillbirth Gardosi et al. BMJ 2005, 2013 N=2625 stillbirths FGR as relevant condition identified in 43-60% www.medicinafetalbarcelona.org/ Prognostic criteria of “poor outcome”-SGA CS for distress and/or neonatal acidosis UtA >p95 CPR <p5 EFW CENTILE <3 N=447 SGA + 447 controls Figueras 2012 Prognostic criteria of “poor outcome”-SGA CS for distress and/or neonatal acidosis UtA >p95 CPR <p5 EFW CENTILE <3 N=447 SGA + 447 controls Figueras 2012 Prognostic criteria of “poor outcome”-SGA CS for distress and/or neonatal acidosis UtA >p95 CPR <p5 EFW CENTILE <3 50% N=447 SGA + 447 controls 40% 30% 20% 10% 0% Controls All normal Any abnormal Figueras 2012 Prognostic criteria of “poor outcome”-SGA CS for distress and/or neonatal acidosis UtA >p95 CPR <p5 EFW CENTILE <3 50% N=447 SGA + 447 controls 40% 30% 20% 10% 8% 0% Controls All normal Any abnormal Figueras 2012 Prognostic criteria of “poor outcome”-SGA CS for distress and/or neonatal acidosis UtA >p95 CPR <p5 EFW CENTILE <3 50% N=447 SGA + 447 controls 40% 30% 20% 10% 8% 11% 0% Controls All normal Any abnormal Figueras 2012 Prognostic criteria of “poor outcome”-SGA CS for distress and/or neonatal acidosis UtA >p95 CPR <p5 EFW CENTILE <3 50% N=447 SGA + 447 controls 40% 40% 30% % 20% 10% 8% 11% 0% Controls All normal Any abnormal 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. Identificar feto pequeño 2. CIR vs. PEG 3. Precoz vs. Tardío 4. Implicación en el manejo clínico www.medicinafetalbarcelona.org/ IUGR= low CPR or high UtA or EFW<p3 or low PlGF 6 SGA? 3 IUGR 0 20 25 30 www.fetalmedicinebarcelona.org/ 35 40 % IUGR= low CPR or high UtA or EFW<p3 or low PlGF 6 SGA? 3 IUGR 0 20 25 30 32w @diagnosis www.fetalmedicinebarcelona.org/ 35 40 % IUGR= low CPR or high UtA or EFW<p3 or low PlGF 6 SGA? 3 IUGR 0 20 25 30 35 32w @diagnosis EARLY IUGR (1%) LATE IUGR (5-7%) www.fetalmedicinebarcelona.org/ 40 % IUGR= low CPR or high UtA or EFW<p3 or low PlGF 6 SGA? 3 IUGR 0 20 25 30 35 32w @diagnosis EARLY IUGR (1%) LATE IUGR (5-7%) PROBLEM: MANAGEMENT PROBLEM: DIAGNOSIS www.fetalmedicinebarcelona.org/ 40 % IUGR= low CPR or high UtA or EFW<p3 or low PlGF 6 SGA? 3 IUGR 0 20 25 35 30 32w @diagnosis EARLY IUGR (1%) LATE IUGR (5-7%) PROBLEM: MANAGEMENT PROBLEM: DIAGNOSIS Placental disease: high (UA+, PE high) Placental disease: low (UA-, PE low) www.fetalmedicinebarcelona.org/ 40 % IUGR= low CPR or high UtA or EFW<p3 or low PlGF 6 SGA? 3 IUGR 0 20 25 35 30 32w @diagnosis EARLY IUGR (1%) LATE IUGR (5-7%) PROBLEM: MANAGEMENT PROBLEM: DIAGNOSIS Placental disease: high (UA+, PE high) Placental disease: low (UA-, PE low) Hypoxia ++: systemic CV adaptation Hypoxia +/-: central CV adaptation www.fetalmedicinebarcelona.org/ 40 % IUGR= low CPR or high UtA or EFW<p3 or low PlGF 6 SGA? 3 IUGR 0 20 25 35 30 32w @diagnosis EARLY IUGR (1%) LATE IUGR (5-7%) PROBLEM: MANAGEMENT PROBLEM: DIAGNOSIS Placental disease: high (UA+, PE high) Placental disease: low (UA-, PE low) Hypoxia ++: systemic CV adaptation Hypoxia +/-: central CV adaptation Tolerance to hypoxia. Natural history Low tolerance: no natural history www.fetalmedicinebarcelona.org/ 40 % IUGR= low CPR or high UtA or EFW<p3 or low PlGF 6 SGA? 3 IUGR 0 20 25 35 30 32w @diagnosis EARLY IUGR (1%) LATE IUGR (5-7%) PROBLEM: MANAGEMENT PROBLEM: DIAGNOSIS Placental disease: high (UA+, PE high) Placental disease: low (UA-, PE low) Hypoxia ++: systemic CV adaptation Hypoxia +/-: central CV adaptation Tolerance to hypoxia. Natural history Low tolerance: no natural history High mortality and morbidity Low mortality but poor long outcome. www.fetalmedicinebarcelona.org/ 40 % FETAL DETERIORATION IN PLACENTAL INSUFFICIENCY PLACENTAL DISEASE COMPENSATED HYPOXIA DECOMPENSATED HYPOXIA SERIOUS INJURY DEATH Increment placental impedance CPR / UMBILICAL A. Centralization MIDDLE CEREBRAL A. cardiac ischemia Diastolic failure growth CTG ABNORMAL Systolic cardiac failure www.fetalmedicinebarcelona.org/ FETAL DETERIORATION IN PLACENTAL INSUFFICIENCY PLACENTAL DISEASE COMPENSATED HYPOXIA DECOMPENSATED HYPOXIA SERIOUS INJURY DEATH Increment placental impedance CPR / UMBILICAL A. Centralization MIDDLE CEREBRAL A. cardiac ischemia Diastolic failure growth DUCTUS VENOSUS CTG ABNORMAL Systolic cardiac failure www.fetalmedicinebarcelona.org/ FETAL DETERIORATION IN PLACENTAL INSUFFICIENCY PLACENTAL DISEASE COMPENSATED HYPOXIA DECOMPENSATED HYPOXIA SERIOUS INJURY DEATH Increment placental impedance UTERINE A. CPR / UMBILICAL A. Centralization MIDDLE CEREBRAL A. cardiac ischemia Diastolic failure growth DUCTUS VENOSUS CTG ABNORMAL Systolic cardiac failure www.fetalmedicinebarcelona.org/ FETAL DETERIORATION IN PLACENTAL INSUFFICIENCY PLACENTAL DISEASE COMPENSATED HYPOXIA DECOMPENSATED HYPOXIA SERIOUS INJURY DEATH Increment placental impedance UTERINE A. CPR / UMBILICAL A. Centralization MIDDLE CEREBRAL A. cardiac ischemia Diastolic failure growth DUCTUS VENOSUS cCTG: reduced shortterm variability CTG ABNORMAL Systolic cardiac failure www.fetalmedicinebarcelona.org/ FETAL DETERIORATION IN PLACENTAL INSUFFICIENCY PLACENTAL DISEASE COMPENSATED HYPOXIA DECOMPENSATED HYPOXIA SERIOUS INJURY DEATH Increment placental impedance UTERINE A. CPR / UMBILICAL A. Centralization MIDDLE CEREBRAL A. Ao ISTHMUS cardiac ischemia Diastolic failure growth DUCTUS VENOSUS cCTG: reduced shortterm variability CTG ABNORMAL Systolic cardiac failure www.fetalmedicinebarcelona.org/ Early-onset IUGR PROBLEM #1: MORTALITY <26 Perinatal Mortality >90% 26-28 30-‐40% www.medicinafetalbarcelona.org/ >28 <10% Baschat 2003 Hecher 2003 Grivell 2010 Cruz-‐Lemini 2012 Early-onset IUGR PROBLEM #1: MORTALITY 60% DVa (rev) 19% Yes <26 Perinatal Mortality >90% No 26-28 30-‐40% www.medicinafetalbarcelona.org/ >28 <10% Baschat 2003 Hecher 2003 Grivell 2010 Cruz-‐Lemini 2012 Early-onset IUGR PROBLEM #1: MORTALITY cCTG-‐STV<3 ms Pathological CGT 60% DVa (rev) 19% Yes <26 Perinatal Mortality >90% No 26-28 30-‐40% www.medicinafetalbarcelona.org/ >28 <10% Baschat 2003 Hecher 2003 Grivell 2010 Cruz-‐Lemini 2012 Early-onset IUGR PROBLEM #1: MORTALITY cCTG-‐STV<3 ms Pathological CGT BPP 60% DVa (rev) IUFD 23% in BPP=6 and 11% in BPP=8 Poor correlation with DVa(rev) Cochrane: poor contribution to prediction 19% Baschat 2007, Kafur 2008, Lalor 2010, Crispi 2009 Yes <26 Perinatal Mortality >90% No 26-28 30-‐40% www.medicinafetalbarcelona.org/ >28 <10% Baschat 2003 Hecher 2003 Grivell 2010 Cruz-‐Lemini 2012 Early-onset IUGR PROBLEM #2: (NEUROLOGICAL) MORBIDITY <29 Neurologic Morbidity >90% 29-32 30-‐40% >32.0 <10% Fouron 2004 Del Rio 2008 Cruz-‐MarQnez 2012 www.medicinafetalbarcelona.org/ Early-onset IUGR PROBLEM #2: (NEUROLOGICAL) MORBIDITY Brain US anomalies in 30w IUGR Controls IUGR antegrade AoI IUGR retrograde AoI Controls IUGR DV<5 z-score IUGR DV>5 z-score 60 * * (%) 45 30 15 0 <29 Neurologic Morbidity >90% 29-32 30-‐40% >32.0 <10% Fouron 2004 Del Rio 2008 Cruz-‐MarQnez 2012 www.medicinafetalbarcelona.org/ Early-onset IUGR PROBLEM #2: (NEUROLOGICAL) MORBIDITY Brain US anomalies in 30w IUGR Controls IUGR antegrade AoI IUGR retrograde AoI Controls IUGR DV<5 z-score IUGR DV>5 z-score 60 * * (%) 45 30 15 0 <29 Neurologic Morbidity >90% 29-32 30-‐40% >32.0 <10% Fouron 2004 Del Rio 2008 Cruz-‐MarQnez 2012 www.medicinafetalbarcelona.org/ FETAL DETERIORATION IN PLACENTAL INSUFFICIENCY EARLY VS LATE IUGR (>34s) PLACENTAL DISEASE COMPENSATED HYPOXIA DECOMPENSATED HYPOXIA SERIOUS INJURY DEATH Increment placental impedance UMBILICAL A. Centralization MIDDLE CEREBRAL A. growth DUCTUS VENOSUS cardiac ischemia Diastolic failure CTG / BPP ABNORMAL Systolic cardiac failure www.medicinafetalbarcelona.org/ FETAL DETERIORATION IN PLACENTAL INSUFFICIENCY EARLY VS LATE IUGR (>34s) PLACENTAL DISEASE COMPENSATED HYPOXIA Increment placental impedance DECOMPENSATED HYPOXIA SERIOUS INJURY DEATH Placental injury <30% UMBILICAL A. Centralization MIDDLE CEREBRAL A. growth DUCTUS VENOSUS cardiac ischemia Diastolic failure CTG / BPP ABNORMAL Systolic cardiac failure www.medicinafetalbarcelona.org/ FETAL DETERIORATION IN PLACENTAL INSUFFICIENCY EARLY VS LATE IUGR (>34s) PLACENTAL DISEASE Increment placental impedance COMPENSATED HYPOXIA DECOMPENSATED HYPOXIA SERIOUS INJURY DEATH Placental injury <30% UMBILICAL A. Centralization MIDDLE CEREBRAL A. growth DUCTUS VENOSUS cardiac ischemia Diastolic failure CTG / BPP ABNORMAL Systolic cardiac failure www.medicinafetalbarcelona.org/ FETAL DETERIORATION IN PLACENTAL INSUFFICIENCY EARLY VS LATE IUGR (>34s) PLACENTAL DISEASE Increment placental impedance COMPENSATED HYPOXIA DECOMPENSATED HYPOXIA SERIOUS INJURY DEATH Placental injury <30% UMBILICAL A. Centralization MIDDLE CEREBRAL A. growth DUCTUS VENOSUS cardiac ischemia Diastolic failure mild hypoxia no cardiovascular adaptation www.medicinafetalbarcelona.org/ CTG / BPP ABNORMAL Systolic cardiac failure FETAL DETERIORATION IN PLACENTAL INSUFFICIENCY EARLY VS LATE IUGR (>34s) PLACENTAL DISEASE Increment placental impedance COMPENSATED HYPOXIA DECOMPENSATED HYPOXIA SERIOUS INJURY DEATH Placental injury <30% UMBILICAL A. Centralization MIDDLE CEREBRAL A. growth CTG / BPP ABNORMAL mild hypoxia no cardiovascular adaptation www.medicinafetalbarcelona.org/ FETAL DETERIORATION IN PLACENTAL INSUFFICIENCY EARLY VS LATE IUGR (>34s) PLACENTAL DISEASE COMPENSATED HYPOXIA DECOMPENSATED HYPOXIA SERIOUS INJURY DEATH minimal tolerance to hypoxia Increment placental impedance Placental injury <30% UMBILICAL A. Centralization MIDDLE CEREBRAL A. growth CTG / BPP ABNORMAL mild hypoxia no cardiovascular adaptation www.medicinafetalbarcelona.org/ FETAL DETERIORATION IN PLACENTAL INSUFFICIENCY EARLY VS LATE IUGR (>34s) PLACENTAL DISEASE DECOMPENSATED HYPOXIA SERIOUS INJURY DEATH minimal tolerance to hypoxia Increment placental impedance Placental injury <30% UMBILICAL A. Centralization MIDDLE CEREBRAL A. growth CTG / BPP ABNORMAL mild hypoxia no cardiovascular adaptation www.medicinafetalbarcelona.org/ Late-onset intrauterine growth restriction vs. small-for-gestational age (submitted) Figueras 2012 www.medicinafetalbarcelona.org/docencia Late-onset intrauterine growth restriction vs. small-for-gestational age (submitted) 40% of late-SGA with 11 % risk (14% of all adverse outcomes) SGA Figueras 2012 www.medicinafetalbarcelona.org/docencia Late-onset intrauterine growth restriction vs. small-for-gestational age (submitted) 40% of late-SGA with 11 % risk (14% of all adverse outcomes) SGA Late-IUGR 60% of late-SGA with 40% risk (86% of all adverse outcomes) Figueras 2012 www.medicinafetalbarcelona.org/docencia 1. Identificar feto pequeño 2. CIR vs. PEG 3. Precoz vs. Tardío 4. Implicación en el manejo clínico www.medicinafetalbarcelona.org/ IUGR = abnormal CPR or UtA or EFW<p3 Savchev 2013 www.medicinafetalbarcelona.org/ FETAL DETERIORATION IN IUGR PLACENTAL DISEASE COMPENSATED HYPOXIA DECOMPENSATED HYPOXIA SERIOUS INJURY DEATH Increment placental impedance Centralization cardiac ischemia Diastolic failure Systolic cardiac failure www.fetalmedicinebarcelona.org/ FETAL DETERIORATION IN IUGR PLACENTAL DISEASE COMPENSATED HYPOXIA DECOMPENSATED HYPOXIA SERIOUS INJURY DEATH Increment placental impedance Centralization cardiac ischemia Diastolic failure cCTG: reduced STV Systolic cardiac failure www.fetalmedicinebarcelona.org/ FETAL DETERIORATION IN IUGR PLACENTAL DISEASE COMPENSATED HYPOXIA DECOMPENSATED HYPOXIA SERIOUS INJURY DEATH Diagnostic/chronic markers Early and Late IUGR Increment placental impedance Centralization cardiac ischemia Diastolic failure cCTG: reduced STV Systolic cardiac failure www.fetalmedicinebarcelona.org/ FETAL DETERIORATION IN IUGR PLACENTAL DISEASE COMPENSATED HYPOXIA Diagnostic/chronic markers Early and Late IUGR DECOMPENSATED HYPOXIA SERIOUS INJURY DEATH Prognostic/Acute markers Early IUGR Increment placental impedance Centralization cardiac ischemia Diastolic failure cCTG: reduced STV Systolic cardiac failure www.fetalmedicinebarcelona.org/ FETAL DETERIORATION IN IUGR PLACENTAL DISEASE COMPENSATED HYPOXIA Diagnostic/chronic markers Early and Late IUGR DECOMPENSATED HYPOXIA SERIOUS INJURY DEATH Prognostic/Acute markers Early IUGR Increment placental impedance Centralization cardiac ischemia Diastolic failure cCTG: reduced STV Systolic cardiac failure LOW MODERATE HIGH Risks of prematurity www.fetalmedicinebarcelona.org/ FETAL DETERIORATION IN IUGR PLACENTAL DISEASE COMPENSATED HYPOXIA Diagnostic/chronic markers Early and Late IUGR DECOMPENSATED HYPOXIA SERIOUS INJURY DEATH Prognostic/Acute markers Early IUGR Increment placental impedance Centralization cardiac ischemia Diastolic failure cCTG: reduced STV III II LOW IV MODERATE V HIGH Risks of prematurity www.fetalmedicinebarcelona.org/ Systolic cardiac failure Protocolo CIR Primer paso: si todo N = PEG I II Doppler normal pero PFE<p3 Aumento resistencia placentaria o redistribución inicial III Aumento grave resistencia y/o redistribución grave IV Alteración hemodinámica grave V Alto riesgo de muerte www.medicinafetalbarcelona.org/ Protocolo CIR Primer paso: si todo N = PEG I II Doppler normal pero PFE<p3 Aumento resistencia placentaria o redistribución inicial CPR <p5 III Aumento grave resistencia y/o redistribución grave IV Alteración hemodinámica grave V Alto riesgo de muerte www.medicinafetalbarcelona.org/ Ut A >p95 MCA <p5 Protocolo CIR Primer paso: si todo N = PEG I II Doppler normal pero PFE<p3 Aumento resistencia placentaria o redistribución inicial III Aumento grave resistencia y/o redistribución grave CPR <p5 AEDV IV Alteración hemodinámica grave V Alto riesgo de muerte www.medicinafetalbarcelona.org/ MCA <p5 Ut A >p95 AoI >p95 Protocolo CIR Primer paso: si todo N = PEG I II Doppler normal pero PFE<p3 Aumento resistencia placentaria o redistribución inicial III Aumento grave resistencia y/o redistribución grave CPR <p5 AEDV DV >p95 IV Alteración hemodinámica grave V MCA <p5 Ut A >p95 Alto riesgo de muerte www.medicinafetalbarcelona.org/ AoI >p95 REDV UVpuls Protocolo CIR Primer paso: si todo N = PEG I II Doppler normal pero PFE<p3 Aumento resistencia placentaria o redistribución inicial III Aumento grave resistencia y/o redistribución grave CPR <p5 AEDV DV >p95 IV Alteración hemodinámica grave V MCA <p5 Ut A >p95 AoI >p95 REDV DV (a rev) Alto riesgo de muerte www.medicinafetalbarcelona.org/ UVpuls CGT decelerations of reduced short-term variability IUGR Management protocol according to severity stages Stage Follow-‐up IV III II Daily 1-‐2 d 2/w 1/w DV(a-‐) cCTG abn. CTG dec. Delivery Mode CS <26w Mort. Morb. V >90% 26-28 50% >90% (a) 28 w DV>p95 / UV puls (b) 30 w REDV CS 28-32 <10% 50% www.medicinafetalbarcelona.org/ EFW<p3 CPR>p95 UtA>p95 MCA<p5 (a) AEDV (b) AoI>95 CS or LI 32-34 I LI 34-37 IUGR Management protocol according to severity stages Stage Follow-‐up IV III II Daily 1-‐2 d 2/w 1/w DV(a-‐) cCTG abn. CTG dec. Delivery Mode CS <26w Mort. Morb. V >90% 26-28 50% >90% (a) 28 w DV>p95 / UV puls (b) 30 w REDV CS 28-32 <10% 50% www.medicinafetalbarcelona.org/ EFW<p3 CPR>p95 UtA>p95 MCA<p5 (a) AEDV (b) AoI>95 CS or LI 32-34 I LI 34-37 IUGR Management protocol according to severity stages Stage Follow-‐up IV III II Daily 1-‐2 d 2/w 1/w DV(a-‐) cCTG abn. CTG dec. Delivery Mode CS <26w Mort. Morb. V >90% 26-28 50% >90% (a) 28 w DV>p95 / UV puls (b) 30 w REDV CS 28-32 <10% 50% www.medicinafetalbarcelona.org/ EFW<p3 CPR>p95 UtA>p95 MCA<p5 (a) AEDV (b) AoI>95 CS or LI 32-34 I LI 34-37 IUGR Management protocol according to severity stages Stage Follow-‐up IV III II Daily 1-‐2 d 2/w 1/w DV(a-‐) cCTG abn. CTG dec. Delivery Mode CS <26w Mort. Morb. V >90% 26-28 50% >90% (a) 28 w DV>p95 / UV puls (b) 30 w REDV CS 28-32 <10% 50% www.medicinafetalbarcelona.org/ EFW<p3 CPR>p95 UtA>p95 MCA<p5 (a) AEDV (b) AoI>95 CS or LI 32-34 I LI 34-37 Feto pequeño debe dividirse en: CIR (placenta, mal resultado perinatal y a largo plazo) PEG (no se sabe, resultado perinatal N, malo a largo plazo) CIR precoz y tardío (EG 32s) presentan diferencias fisiopatológicas y clínicas marcadas A nivel clínico, un sólo protocolo integrado permite optimizar decisión en todos los casos www.medicinafetalbarcelona.org/ www.medicinafetalbarcelona.org www.medicinafetalbarcelona.org/
