ACTUALIZACIÓN EN CRECIMIENTO INTRAUTERINO RESTRINGIDO

Transcription

ACTUALIZACIÓN EN CRECIMIENTO
INTRAUTERINO RESTRINGIDO
Eduard Gratacós
BCNatal – Barcelona Center of Maternal-Fetal and Neonatal Medicine
Hospital Clínic and Hospital Sant Joan de Déu, Universitat de Barcelona
www.fetalmedicinebarcelona.org/
“SMALL FETUSES” AND MORTALITY AT TERM
50%
45%
40%
30%
30%
25%
20%
10%
0%
FGR
Unknown
Others
Gardosi 2005 and 2013
Figueras 2012
www.medicinafetalbarcelona.org/
Gardosi et al. BMJ 2005 and 2013
Overall stillbirth / 1000 births: 2.4 in
non-SGA vs19.8 in not detected SGA
n = 26 968
Lindquist and Molin, 2005
Fetal weight centile
Placental insufficiency = high risk of IUFD and fetal/neonatal acidosis
50
Fetal Smallness =
higher risk of placental
insufficiency
10
“Small
fetuses”
Non-“respiratory” smallness
= no distress/IUFD risk
Placental “respiratory”
smallness = risk distress + IUFD
0
100
Risk of placental insufficiency
1. Identificación del feto “pequeño”
2. Distinguir insuficiencia placentaria (CIR
3. Determinar seguimiento y parto
vs
PEG)
Neonatal vs Fetal GA “normal” weight in the same population
IMPROVING DETECTION & DEFINITION OF “RESTRICTION”
Birthweight inverse relation with perinatal outcome AND brain-cardiac remodelling
A
E
S
RE
H
C
R
Mula 2013, Lobmaier 2013,
Khalil 2014, Nicolaides 2015
decrease2of2fetal2movements
5-15% during 3rd trimester
30% perinatal complications; 10-15% term stillbirth
4% preterm delivery
1% stillbirth
stillbirth
reduction
OR 0.36
25% IUGR
increase IUGR
detection
(IUGR > 36 w not
diagnosed before)
70% Normal
www.medicinafetalbarcelona.org
Neonatal vs Fetal GA “normal” weight in the same population
2. Distinguir insuficiencia placentaria (CIR
vs
PEG)
Fetal weight centile
Placental insufficiency = high risk of IUFD and fetal/neonatal acidosis
50
Fetal Smallness =
higher risk of placental
insufficiency
10
“Small
fetuses”
Non-“respiratory” smallness
= no distress/IUFD risk
Placental “respiratory”
smallness = risk distress + IUFD
0
100
Risk of placental insufficiency
Exclude primary fetal defect
Exclude extrinsic cause
ISOLATED FETAL SMALLNESS (= POORER PROGNOSIS)
Perinatal and Long-term Outcomes
Poor perinatal outcome + IUFD
(Doppler) Signs of adaptation
Perinatal outcome normal - No IUFD
NO signs of adaptation
FGR
Placental insufficiency
SGA
Unknown (constitutional + others)
FGR vs. SGA: DIFFERENT MANAGEMENT
The discovery of UA and hemodynamics of FGR
Constitutionally small
Extrinsic cause
Primary fetal
defect
SGA
FGR
N2cases
UA Doppler +
(EARLY-ONSET)
0
UA Doppler N
(LATE-ONSET)
N2cases
20
25
30
35
40
FGR = abnormal UA Doppler
Savchev22013
Evidence #1:
SGA + NORMAL UA DOPPLER = POORER OUTCOMES
(n= 376)
40
30
%
20
10
0
Neonatal acidosis
CS for distress
Abnormal NBAS
Any
Figueras 2011
Evidence #2: “SGA” HAVE HIGHER RISK OF IUFD AT TERM
50%
NON-DETECTED
IUGR AND TERM
MORTALITY
Barcelona
2005-2014
45%
40%
30%
30%
25%
20%
10%
0%
FGR
Unknown
Others
Stillbirth by relevant condition at birth (ReCoDe)
Gardosi et al. BMJ 2005 and 2013
IUGR as relevant condition identified in 43-60%
Overall stillbirth / 1000 births: 2.4 in non-SGA VS. 19.8 in not detected SGA
n
.
o
CIR = ¿Doppler
AU anormal?
Ya
N2cases
UA Doppler +
(EARLY-ONSET)
0
UA Doppler N
(LATE-ONSET)
N2cases
20
25
30
35
40
Savchev22013
Prognostic criteria for poor outcome among small fetuses
with normal UA Doppler
CPR
<p5
Risk of CS for distress and/or
neonatal acidosis
N=509 SGA + 509 controls
50%
UtA
>p95
40%
40%
%
30%
20%
EFW CENTILE <3
10%
8%
11%
0%
Controls
All normal
Any abnormal
Figueras 2012
Cerebroplacental ratio is more
sensitive than UA or MCA alone
IPUA=p80
IPMCA=p20
+
=
CPR
<p5
CIR = PFE <p10 + cualquiera de
CPR
<p5
UtA
>p95
EFW CENTILE <3
Figueras 2012
Distribution of cases when FGR = abnormal UA Doppler
Savchev 2013
Distribution of cases when FGR = abnormal CPR or UtA or EFW<p3
Savchev 2013
Exclude primary fetal defect
Exclude extrinsic cause
ISOLATED FETAL SMALLNESS = POORER PROGNOSIS
Perinatal and Long-term Outcomes
Poor perinatal outcome + IUFD
(Doppler) Signs of adaptation
Perinatal outcome normal - No IUFD
NO signs of adaptation
FGR
SGA
Unknown (constitutional + others)
FGR vs. SGA: DIFFERENT MANAGEMENT
2. Distinguir insuficiencia placentaria (CIR vs PEG)
FGR = abnormal CPR or UtA or EFW<p3
Management = when should we deliver?
Early-severe
High risk IUFD preterm
PROBLEM:TIMING DELIVERY
Q: Delivery? Next exam?
Late-mild
No IUFD <37w (risk at term)
PROBLEM: DETECTION
Q: Is it FGR or SGA?
Savchev 2013
FGR = abnormal CPR or UtA or EFW<p3
Savchev 2013
RATIONALE FOR AN INTEGRATED STAGE-BASED
APPROACH TO THE MANAGEMENT OF FGR
PLACENTAL DISEASE
HYPOXIA
ACIDOSIS
Diagnostic/chronic markers
DIFFERENCE
FGR VS
SGA
Increment
placental
SERIOUS INJURY
DEATH
Prognostic/Acute markers
INDICATION ABOUT THE SHORT-TERM RISK
OF IUFD/BRAIN INJURY
impedance
Centralization
cardiac ischemia
Diastolic failure
cCTG: reduced STV
BPP < 4
Stage fetal
deterioration
I
II
III
IV
deliver when risks are:
Risks of
prematurity
MINIMAL
MILD
HIGH
Systolic cardiac
failure
FGR
Management protocol according to severity stages
Stage
IV
III
II
I
DV>p95,&REDV
AEDV,&AoI>95
EFW<p3,&CPR&<p5,&UtA>95
VERY&HIGH
HIGH
MODERATE
LOW
Deliver'at
Any&1me
30
34
37
Follow=up
Hours/Daily
162&d
2/w
1/w
CS
CS
CS&or&LI
LI
DV(a6),&cCTG,&CTG&dec
Risk'of'IUFD/
brain'injury
Mode
<26w
Mort.&&&&
Morb.&
>90%&
&
26-28
50%&
>90%&
28-30
30-34
<10%
&
50%
34-37
Stage 1
Delivery
Primer objetivo:
Identificación del feto “pequeño” (PFE<p10)
Segundo objetivo:
Clasificar como CIR vs PEG con RCP, AUt y PFE<3.
Tercer objetivo:
Decidir pauta seguimiento y momento del parto:
utilizar un protocolo integrado basado en estadíos.

ACTUALIZACIÓN EN CRECIMIENTO INTRAUTERINO RESTRINGIDO

Transcription

Similar documents

Presentación de PowerPoint

early iugr - medicinafetalbarcelona

Fundal Height Measurement