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IUGR: When
should we deliver
the baby?
Ivica Zalud, MD, PhD
Professor and Acting Chair
John A Burns School of Medicine
University of Hawaii, Honolulu, USA
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OBJECTIVES:
•
Define IUGR vs. SGA fetuses
•
Discuss antenatal natural history
•
Present antepartum and intrapartum
management (optimal delivery)
•
Discuss short and long term sequelae
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IUGR
•
Nomenclature
: low birth weight, small for
gestational age, retarded fetal growth, small for
dates, intrauterine growth restriction
•
Definition:
–
IUGR is defined as a birth weight less than the
10
th
percentile (? 5
th
percentile or ?>2SD below
the mean) at given gestational age.
–
The fetus has not reached its growth
potential at given gestational age due to
one or more causative factors.•
Infant weight is the single most important factor
affecting neonatal mortality!
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IUGR
•
ACOG: IUGR is one of the most common and
complex problems in obstetrics
•
Problems: –
Inconsistent definitions
–
Poor detection rate
–
Limited preventive and treatment options
–
Multiple associated morbidities
–
Increased likelihood of perinatal mortality
–
Impaired intellectual development, hypertension and
obesity in adulthood
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IUGR: So what!
•
2
nd
leading
contributor to
perinatalmortality!!!
•
Perinatal mortality:
x6
-
10•
Intrapartum asphyxia:
up to 50%•
As many as 40% stillborns are IUGR
•
A portion of perinatal complications is
preventable
(morbidity and mortality)•
Association with
multiple sequelae
(short and long term morbidity)
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IUGR
•
The fetus genetically programmed to be in
the 90
th
percentile who is born in the 20
th
percentile may be in more trouble than a
baby born to a jockey and a gymnast who
is in the 8
th
percentile!
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SONOGRAPHIC FINDINGS
• Doppler studies
– Arterial: UA, MCA, uterine artery
– Venous: IVC, DV – Semi quantitative measurements:
• Waveform analysis: RI, S/D, PI
•
Absent end-diastolic flow• Reversed end-diastolic flow
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Doppler
inIUGRfetuses
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Umbilical Artery DopplerMeta-analyses
• Absent or reversed EDF – 80x increase inperinatal mortality (Thornton 1993 )
• UA Doppler significantly reduces IUFD
– Divon 1995 : 8 studies, 6838 Pts
– Giles 1993 : 6 studies, 4335 Pts
– Alfirevic 1995 : 12 studies, 38% reductions inperinatal mortality
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Doppler in IUGR
Doppler meta analysis has shown that the use of
the UA Doppler reduces the number of:
•antenatal admissions: 44%
• inductions of labor: 29%
• C/S for NRFS: 52%
•
perinatal mortality: 38%
Alfirevic Z, Neilson JP
ACOG 1995;172;1379-87
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Does Doppler improve outcomes inIUGR fetuses?
• It can, when used in conjunction withother diagnostic tools.
• Early compensatory phase (fetal hypoxia): – Biometry & arterial Doppler
• Late phase (fetal acidosis and impendingcardiovascular collapse): – Venous Doppler, FHR analysis & BPP
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IUGR Challenge
• Diagnose true IUGR
• Identify markers of morbidity
• Intervene in a timely fashion
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Fetal Surveillance
• Risk of NRFS is 86% when both umbilical& MCA Dopplers are abnormal
• Risk of NRFS is 4% when both umbilical &MCA Dopplers are normal
Ultrasound Obstet Gyencol 2002;19:225
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TIMELINE FOR FETAL HYPOXIA
• Abnormal fetal growth
• Abnormal arterial Doppler (UA, MCA)
– ~ 2 weeks
• Abnormal venous Doppler (IVC & ductusvenosus)
– ~ 1-2 days??
• Abnormal NST / BPP score
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PREGNANCY MANAGEMENT
• The crux of management: hazards ofprematurity vs. threat of IUFD
•Referral to maternal fetal medicinesubspecialist – targeted ultrasound andcounseling
• Search for etiology: fetal, placental,maternal
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PREGNANCY MANAGEMENT
• Fetal karyotype (2-5% abnormal – Creasy& Resnik 1999)
• NST, BPP, CST, UA Doppler
• Serial biometry (q 3-4 weeks) – watch
head growth
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PREGNANCY MANAGEMENT• Abnormal UA Doppler
– Decreased diastolic flow• Increase frequency of testing; consider deliver >37
weeks
– Absent end diastolic flow• Steroids; consider delivery at 34 weeks
– Reversed end diastolic flow• Steroids: consider delivery at 32 weeks
Am J Obstet Gynecol. 2012 Apr;206(4):300-8.
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Berkley E, Chauhan SP, Abuhamad A.
Doppler assessment of the fetus with intrauterine growth restriction.
Am J Obstet Gynecol. 2012 Apr;206(4):300-8.
• Relevant studies were identified usingPubMed (US National Library of Medicine,
1983 through 2011) publications inEnglish, which describe the peripartumoutcomes of IUGR according to Doppler
assessment of:•umbilical arterial
•middle cerebral artery
•ductus venosus.
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Berkley E, Chauhan SP, Abuhamad A.
Doppler assessment of the fetus with intrauterine growth restriction.
Am J Obstet Gynecol. 2012 Apr;206(4):300-8.
• R andomized and quasi-randomizedstudies: UA Doppler significantlydecreases the likelihood (1.2% vs 1.7%;
RR, 0.71; 95% confidence interval, 0.52-0.98).
• labor induction
• cesarean delivery• perinatal deaths
• Antepartum surveillance with UA Doppler
should be started when the fetus is viable
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Berkley E, Chauhan SP, Abuhamad A.
Doppler assessment of the fetus with intrauterine growth restriction.
Am J Obstet Gynecol. 2012 Apr;206(4):300-8.
• Although Ductus venous, MCA and othervessels have some prognostic value forIUGR fetuses, there is a lack of
randomized trials showing benefit.
• Doppler studies of vessels other than theUA, as part of assessment of fetal well-being in pregnancies complicated byIUGR, should be reserved for research
protocols.
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Delivery• The optimal timing of delivery depends on
the underlying etiology of the growthrestriction (if known) as well as theestimated gestational age.
• The patient makes informed decision
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Delivery
•
Altering the timing of delivery for fetuseswith aneuploidy or congenital infectionmay not improve the outcome.
• In some cases patients may electnonintervention.
• Some women may choose to forgodelivery of a severely growth-restrictedfetus at 25 weeks of gestation even if
there is an increased risk of fetal death.
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Delivery
•
Management may be enhanced by anindividualized and multidisciplinaryapproach.
• When intervention for perinatal benefit is
the preferred option, antenatal fetalsurveillance may help guide the timing ofdelivery.
•IUGR alone is not an indication forcesarean delivery and the route of deliveryshould be based on other clinicalcircumstances.
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GRIT Trial
• The only published randomized trial toassess the timing of delivery of the earlypreterm (<34 weeks) IUGR fetus.
• Pts whose OBs were uncertain whetherdelivery would be beneficial, wererandomized: – early delivery group (delivery within 48 hours)
or
– expectant management group (with
antepartum surveillance until it was felt thatdelivery should not be delayed any longer).
BJOG 2003;110:27 – 32 Lancet 2004;364:513 – 20 AJOG 2011;204:34.e1 – 34.e9
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GRIT Trial
• The rates of betamethasone administrationwere the same in both groups.
• Perinatal survival was similar.
• At the 6 – 12-year follow-up there were nodifferences in cognitive, language, behavior,or motor abilities of the children born towomen in the early-delivery group versus
those in the expectant management group.
BJOG 2003;110:27 – 32 Lancet 2004;364:513 – 20 AJOG 2011;204:34.e1 – 34.e9
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DIGIT Trial
• In the Disproportionate IntrauterineGrowth Intervention Trial at Term,women with singleton gestations at or
beyond 36 weeks with suspected IUGRwere randomized: – undergo delivery or
–
expectant management with delivery onlyif some other indication arose.
BMJ 2010;341:c7087.
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DIGIT Trial
•
There were no differences in compositeneonatal outcome between these twogroups.
• The study cohort was not large enoughto determine whether individualoutcomes, such as perinatal death,
were affected by the differentmanagement approaches.
BMJ 2010;341:c7087.
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Delivery: NICHD, SMFM, ACOG
•
Existing data and expert consensus, a joint conference of the NICHD , SMFMand ACOG suggested the following twotiming strategies:
1) Delivery at 38 0/7 – 39 6/7 weeks ofgestation in cases of isolated fetal
growth restriction
Obstet Gynecol 2011;118:323 – 33.
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Delivery: NICHD, SMFM, ACOG
2) Delivery at 34 0/7 –
37 6/7 weeks ofgestation in cases of IUGR with additionalrisk factors for adverse outcome
– oligohydramnios
– abnormal umbilical artery Doppler – maternal risk factors
– comorbidities
Obstet Gynecol 2011;118:323 – 33.
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Delivery: NICHD, SMFM, ACOG
3) Delivery before 34 weeks• At a center with a NICU and, ideally, afterconsultation with a maternal – fetal specialist.
•Corticosteroids should be administeredbefore delivery (improved preterm neonataloutcomes).
•For cases in which delivery occurs before 32
weeks of gestation, magnesium sulfate shouldbe considered for fetal and neonatalneuroprotection
Obstet Gynecol 2011;118:323 – 33.
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PREGNANCY MANAGEMENT
• 37 or more: delivery if NRFS; electivedelivery after 38-39 weeks
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PREGNANCY MANAGEMENT
• 34-37 weeks – Management individualized
– Antepartum testing: NST/AFI twice weekly,UA Doppler
– Non-reassuring status: evaluate for delivery
– Oligohydramnios and abnormal UA Doppler:more frequent antepartum testing but not
delivery (unless non-reassuring status)
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PREGNANCY MANAGEMENT
• <34 weeks: – Expectant management if reassuring fetal
status – Rx steroids for fetal benefits
– Antepartum testing: NST/AFI & BPP twiceweekly, daily kick counts, UA Doppler
– Abnormal UA Doppler: daily NST and at leasttwice weekly BPP for up to 2 weeks
–
Non-reassuring status: evaluate for delivery
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IUGR
• What are benefits of UA Doppler?
• Significant reduction of laborinduction (RR 0.89), C/S (RR 0.9)
and perinatal deaths (RR 0.71) –
number needed to to treat: 203
Alfirevic et all. Cochrane Database 2010
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TERM IUGR
• Mode of delivery – Based entirely on standard obstetric practice
– No evidence to support routine C/S
– Consideration for C/S if non-reassuring antepartumtesting with an unfavorable cervix
– Labor induction with or without cx ripening
• Continuous electronic fetal monitoring
• FHR monitor: Increased risk for decreased variability and late
decelerations
• Meconium
– Optimum: Tertiary care centers with MFM and NICUavailable
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LONG-TERM OUTCOME
• Depend on underlying cause
• Poor cognitive function
• Adverse neurological outcome in childhood
• Impaired gross motor development,hyperactivity, poor concentration, lower
IQ, speech and reading disabilities(Gembruch & Gortner 1998 )
• Cerebral palsy
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LONG-TERM OUTCOME
• David Barker, epidemiologist from England
– Fetal origin of adult diseases: The risk ofcoronary artery disease, stroke and hypertension
– Intrauterine conditions could programdevelopment of the cardiovascular system later inlife
– Infants with birth weight less than 5.5 lb had a 3x
increase in death due to coronary artery diseaselater in life.
• Other risks:
– Abdominal obesity, type 2 diabetes mellitus,
hyperlipidemia
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KEY POINTS:
• IUGR alone is not an indication for cesareandelivery.
• The optimal timing of delivery depends on the
underlying etiology of the growth restriction (ifknown) as well as the estimated gestational age.
• Proposed Performance Measure (ACOG)% of patients with suspected IUGR in whom a plan for assessmentand surveillance of fetal growth and well-being is initiated, if deliveryis not pursued at the time of diagnosis
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KEY POINTS:
• In managing IUGR pregnancies, timing ofdelivery is the most critical step.
• The challenge is to balance the risk ofprematurity with the risk of IUFD,
neonatal morbidity and mortality and longterm neurodevelopmental delay.
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Hawaii, USA