UPDATE ON DIAGNOSIS AND MANAGEMENT OF FETAL … · PROBLEM: MANAGEMENT PROBLEM: DIAGNOSIS Placental...
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www.fetalmedicinebarcelona.org / UPDATE ON DIAGNOSIS AND MANAGEMENT OF FETAL GROWTH RESTRICTION Eduard Gratacos Servicio de Medicina Maternofetal Hospital Clinic y Hospital Sant Joan de Deu - Universidad de Barcelona www.fetalmedicinebarcelona.org
Transcript of UPDATE ON DIAGNOSIS AND MANAGEMENT OF FETAL … · PROBLEM: MANAGEMENT PROBLEM: DIAGNOSIS Placental...
www.fetalmedicinebarcelona.org/
UPDATE ON DIAGNOSIS AND MANAGEMENT OF
FETAL GROWTH RESTRICTIONEduard Gratacos
Servicio de Medicina MaternofetalHospital Clinic y Hospital Sant Joan de Deu - Universidad de Barcelona
www.fetalmedicinebarcelona.org
www.medicinafetalbarcelona.org/
1. Identify small fetus
2. FGR vs. SGA
3. Early vs. Late
4. Stage-based management protocol
www.medicinafetalbarcelona.org/
1. Identify small fetus
2. FGR vs. SGA
3. Early vs. Late
4. Stage-based management protocol
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. Identify small fetus
2. FGR vs. SGA
3. Early vs. Late
4. Stage-based management protocol
www.medicinafetalbarcelona.org/
ISOLATED FETAL SMALLNESS = POORER PROGNOSISPerinatal and Long-term Outcomes
Exclude extrinsic cause
Exclude primary fetal defect
www.medicinafetalbarcelona.org/
ISOLATED FETAL SMALLNESS = POORER PROGNOSISPerinatal and Long-term Outcomes
Exclude extrinsic cause
Exclude primary fetal defect
Poor perinatal outcome + IUFD(Doppler) Signs of adaptation
www.medicinafetalbarcelona.org/
ISOLATED FETAL SMALLNESS = POORER PROGNOSISPerinatal and Long-term Outcomes
Exclude extrinsic cause
Exclude primary fetal defect
Poor perinatal outcome + IUFD(Doppler) Signs of adaptation
Perinatal outcome normal - No IUFDNO signs of adaptation
www.medicinafetalbarcelona.org/
SGA Unknown (constitutional + others)
IUGRPlacental insufficiency
ISOLATED FETAL SMALLNESS = POORER PROGNOSISPerinatal and Long-term Outcomes
Exclude extrinsic cause
Exclude primary fetal defect
Poor perinatal outcome + IUFD(Doppler) Signs of adaptation
Perinatal outcome normal - No IUFDNO signs of adaptation
www.medicinafetalbarcelona.org/
SGA Unknown (constitutional + others)
IUGRPlacental insufficiency
ISOLATED FETAL SMALLNESS = POORER PROGNOSISPerinatal and Long-term Outcomes
Exclude extrinsic cause
Exclude primary fetal defect
Poor perinatal outcome + IUFD(Doppler) Signs of adaptation
Perinatal outcome normal - No IUFDNO signs of adaptation
www.medicinafetalbarcelona.org/
SGA Unknown (constitutional + others)
IUGRPlacental insufficiency
ISOLATED FETAL SMALLNESS = POORER PROGNOSISPerinatal and Long-term Outcomes
Exclude extrinsic cause
Exclude primary fetal defect
Poor perinatal outcome + IUFD(Doppler) Signs of adaptation
Perinatal outcome normal - No IUFDNO signs of adaptation
FGR vs. SGA: DIFFERENT MANAGEMENT
www.medicinafetalbarcelona.org/
Constitutionally small Placental insufficiency Extrinsic cause
Primary fetal defect
SGA FGR
The discovery of UA and hemodynamics of IUGR
www.medicinafetalbarcelona.org/
Constitutionally small Placental insufficiency Extrinsic cause
Primary fetal defect
SGA FGR
The discovery of UA and hemodynamics of IUGR
20 30 4025 35
0
N cases
N cases
www.medicinafetalbarcelona.org/
Constitutionally small Placental insufficiency Extrinsic cause
Primary fetal defect
SGA FGR
The discovery of UA and hemodynamics of IUGR
20 30 4025 35
0
N cases
N cases
UA Doppler +(EARLY-ONSET)
www.medicinafetalbarcelona.org/
Constitutionally small Placental insufficiency Extrinsic cause
Primary fetal defect
SGA FGR
The discovery of UA and hemodynamics of IUGR
20 30 4025 35
0
N cases
N cases
UA Doppler +(EARLY-ONSET)
UA Doppler N(LATE-ONSET)
Savchev 2013
www.medicinafetalbarcelona.org/
Constitutionally small Placental insufficiency Extrinsic cause
Primary fetal defect
SGA FGR
The discovery of UA and hemodynamics of IUGR
FGR = abnormal UA Doppler
20 30 4025 35
0
N cases
N cases
UA Doppler +(EARLY-ONSET)
UA Doppler N(LATE-ONSET)
Savchev 2013
www.medicinafetalbarcelona.org/
0
10
20
30
40
Neonatal acidosis CS for distress Abnormal NBAS Any
%
Figueras 2011
SGA: proportion of perinatal adverse outcomes in 376 consecutive cases
www.medicinafetalbarcelona.org/
IMPACT OF NON-DETECTED IUGR ON LATE FETAL MORTALITYHospital Clínic Barcelona2005-2010
0%
10%
20%
30%
40%
50%
FGR Unknown Others
25%30%
45%
Relevant Condition ReCoDe
www.medicinafetalbarcelona.org/
IMPACT OF NON-DETECTED IUGR ON LATE FETAL MORTALITYHospital Clínic Barcelona2005-2010
0%
10%
20%
30%
40%
50%
FGR Unknown Others
25%30%
45%
Relevant Condition ReCoDe
Impact of growth restriction in late pregnancy stillbirthGardosi et al. BMJ 2005, 2013
N=2625 stillbirths
FGR as relevant condition identified in 43-60%
UtA >p95
CPR <p5 EFW CENTILE <3
Prognostic criteria of “poor outcome”-SGACS for distress and/or neonatal acidosis
N=447 SGA + 447 controls
Figueras 2012
UtA >p95
CPR <p5 EFW CENTILE <3
Prognostic criteria of “poor outcome”-SGACS for distress and/or neonatal acidosis
N=447 SGA + 447 controls
Figueras 2012
UtA >p95
CPR <p5 EFW CENTILE <3
0%
10%
20%
30%
40%
50%
Controls All normal Any abnormal
Prognostic criteria of “poor outcome”-SGACS for distress and/or neonatal acidosis
N=447 SGA + 447 controls
Figueras 2012
UtA >p95
CPR <p5 EFW CENTILE <3
0%
10%
20%
30%
40%
50%
8%
Controls All normal Any abnormal
Prognostic criteria of “poor outcome”-SGACS for distress and/or neonatal acidosis
N=447 SGA + 447 controls
Figueras 2012
UtA >p95
CPR <p5 EFW CENTILE <3
0%
10%
20%
30%
40%
50%
8%11%
Controls All normal Any abnormal
Prognostic criteria of “poor outcome”-SGACS for distress and/or neonatal acidosis
N=447 SGA + 447 controls
Figueras 2012
UtA >p95
CPR <p5 EFW CENTILE <3
0%
10%
20%
30%
40%
50%
8%11%
40%
Controls All normal Any abnormal
%
Prognostic criteria of “poor outcome”-SGACS for distress and/or neonatal acidosis
N=447 SGA + 447 controls
Figueras 2012
www.medicinafetalbarcelona.org/
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
2. FGR vs. SGA
3. Early vs. Late
4. Stage-based management protocol
www.fetalmedicinebarcelona.org/
IUGR
SGA?
20 30 4025 35
0
3
6 %
IUGR= low CPR or high UtA or EFW<p3 or low PlGF
www.fetalmedicinebarcelona.org/
IUGR
SGA?
20 30 4025 35
0
3
6 %
IUGR= low CPR or high UtA or EFW<p3 or low PlGF
32w @diagnosis
www.fetalmedicinebarcelona.org/
IUGR
SGA?
20 30 4025 35
0
3
6 %
IUGR= low CPR or high UtA or EFW<p3 or low PlGF
EARLY IUGR (1%) LATE IUGR (5-7%)
32w @diagnosis
www.fetalmedicinebarcelona.org/
IUGR
SGA?
20 30 4025 35
0
3
6 %
IUGR= low CPR or high UtA or EFW<p3 or low PlGF
EARLY IUGR (1%) LATE IUGR (5-7%)
PROBLEM: MANAGEMENT PROBLEM: DIAGNOSIS
32w @diagnosis
www.fetalmedicinebarcelona.org/
IUGR
SGA?
20 30 4025 35
0
3
6 %
IUGR= low CPR or high UtA or EFW<p3 or low PlGF
EARLY IUGR (1%) LATE IUGR (5-7%)
PROBLEM: MANAGEMENT PROBLEM: DIAGNOSIS
Placental disease: high (UA+, PE high) Placental disease: low (UA-, PE low)
32w @diagnosis
www.fetalmedicinebarcelona.org/
IUGR
SGA?
20 30 4025 35
0
3
6 %
IUGR= low CPR or high UtA or EFW<p3 or low PlGF
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
32w @diagnosis
www.fetalmedicinebarcelona.org/
IUGR
SGA?
20 30 4025 35
0
3
6 %
IUGR= low CPR or high UtA or EFW<p3 or low PlGF
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
32w @diagnosis
www.fetalmedicinebarcelona.org/
IUGR
SGA?
20 30 4025 35
0
3
6 %
IUGR= low CPR or high UtA or EFW<p3 or low PlGF
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.
32w @diagnosis
www.fetalmedicinebarcelona.org/
FETAL DETERIORATION IN PLACENTAL INSUFFICIENCY
PLACENTAL DISEASE COMPENSATED HYPOXIA DECOMPENSATED HYPOXIA SERIOUS INJURYDEATH
cardiac ischemiaDiastolic failure
Systolic cardiac failure
Centralization
Increment placental impedance
growth
MIDDLE CEREBRAL A. <p5
CPR <p5
CTG ABNORMAL
UMBILICAL A. >p95
www.fetalmedicinebarcelona.org/
FETAL DETERIORATION IN PLACENTAL INSUFFICIENCY
PLACENTAL DISEASE COMPENSATED HYPOXIA DECOMPENSATED HYPOXIA SERIOUS INJURYDEATH
cardiac ischemiaDiastolic failure
Systolic cardiac failure
Centralization
Increment placental impedance
growth
MIDDLE CEREBRAL A. <p5
CPR <p5
DUCTUS VENOSUS >p95 and a-
CTG ABNORMAL
UMBILICAL A. >p95
www.fetalmedicinebarcelona.org/
FETAL DETERIORATION IN PLACENTAL INSUFFICIENCY
PLACENTAL DISEASE COMPENSATED HYPOXIA DECOMPENSATED HYPOXIA SERIOUS INJURYDEATH
cardiac ischemiaDiastolic failure
Systolic cardiac failure
Centralization
Increment placental impedance
growth
MIDDLE CEREBRAL A. <p5
CPR <p5
DUCTUS VENOSUS >p95 and a-
CTG ABNORMAL
UTERINE A. >p95
UMBILICAL A. >p95
www.fetalmedicinebarcelona.org/
FETAL DETERIORATION IN PLACENTAL INSUFFICIENCY
PLACENTAL DISEASE COMPENSATED HYPOXIA DECOMPENSATED HYPOXIA SERIOUS INJURYDEATH
cardiac ischemiaDiastolic failure
Systolic cardiac failure
Centralization
Increment placental impedance
growth
MIDDLE CEREBRAL A. <p5
CPR <p5
DUCTUS VENOSUS >p95 and a-
CTG ABNORMAL
UTERINE A. >p95
cCTG: reduced short-term variability
UMBILICAL A. >p95
www.fetalmedicinebarcelona.org/
FETAL DETERIORATION IN PLACENTAL INSUFFICIENCY
PLACENTAL DISEASE COMPENSATED HYPOXIA DECOMPENSATED HYPOXIA SERIOUS INJURYDEATH
cardiac ischemiaDiastolic failure
Systolic cardiac failure
Centralization
Increment placental impedance
growth
MIDDLE CEREBRAL A. <p5
CPR <p5
DUCTUS VENOSUS >p95 and a-
CTG ABNORMAL
UTERINE A. >p95
cCTG: reduced short-term variability
Ao ISTHMUS >p95
UMBILICAL A. >p95
www.medicinafetalbarcelona.org/
FETAL DETERIORATION IN PLACENTAL INSUFFICIENCY EARLY VS LATE IUGR (>34s)
PLACENTAL DISEASE COMPENSATED HYPOXIA DECOMPENSATED HYPOXIA SERIOUS INJURYDEATH
cardiac ischemiaDiastolic failure
Systolic cardiac failure
growth
UMBILICAL A. >p95
DUCTUS VENOSUS >p95 and a-
CTG / BPP ABNORMAL
MIDDLE CEREBRAL A. <p5
CPR <p5
Centralization
Increment placental impedance
www.medicinafetalbarcelona.org/
FETAL DETERIORATION IN PLACENTAL INSUFFICIENCY EARLY VS LATE IUGR (>34s)
PLACENTAL DISEASE COMPENSATED HYPOXIA DECOMPENSATED HYPOXIA SERIOUS INJURYDEATH
cardiac ischemiaDiastolic failure
Systolic cardiac failure
growth
UMBILICAL A. >p95
DUCTUS VENOSUS >p95 and a-
CTG / BPP ABNORMAL
Placental injury <30%
MIDDLE CEREBRAL A. <p5
CPR <p5
Centralization
Increment placental impedance
www.medicinafetalbarcelona.org/
FETAL DETERIORATION IN PLACENTAL INSUFFICIENCY EARLY VS LATE IUGR (>34s)
PLACENTAL DISEASE COMPENSATED HYPOXIA DECOMPENSATED HYPOXIA SERIOUS INJURYDEATH
cardiac ischemiaDiastolic failure
Systolic cardiac failure
growth
UMBILICAL A. >p95
DUCTUS VENOSUS >p95 and a-
CTG / BPP ABNORMAL
Placental injury <30%
MIDDLE CEREBRAL A. <p5
CPR <p5
Centralization
Increment placental impedance
www.medicinafetalbarcelona.org/
FETAL DETERIORATION IN PLACENTAL INSUFFICIENCY EARLY VS LATE IUGR (>34s)
PLACENTAL DISEASE COMPENSATED HYPOXIA DECOMPENSATED HYPOXIA SERIOUS INJURYDEATH
cardiac ischemiaDiastolic failure
Systolic cardiac failure
growth
UMBILICAL A. >p95
DUCTUS VENOSUS >p95 and a-
CTG / BPP ABNORMAL
Placental injury <30%
mild hypoxiano cardiovascular adaptation
MIDDLE CEREBRAL A. <p5
CPR <p5
Centralization
Increment placental impedance
www.medicinafetalbarcelona.org/
FETAL DETERIORATION IN PLACENTAL INSUFFICIENCY EARLY VS LATE IUGR (>34s)
PLACENTAL DISEASE COMPENSATED HYPOXIA DECOMPENSATED HYPOXIA SERIOUS INJURYDEATH
growth
UMBILICAL A. >p95
CTG / BPP ABNORMAL
Placental injury <30%
mild hypoxiano cardiovascular adaptation
MIDDLE CEREBRAL A. <p5
CPR <p5
Centralization
Increment placental impedance
www.medicinafetalbarcelona.org/
FETAL DETERIORATION IN PLACENTAL INSUFFICIENCY EARLY VS LATE IUGR (>34s)
PLACENTAL DISEASE COMPENSATED HYPOXIA DECOMPENSATED HYPOXIA SERIOUS INJURYDEATH
growth
UMBILICAL A. >p95
CTG / BPP ABNORMAL
Placental injury <30%
mild hypoxiano cardiovascular adaptation
minimal tolerance to hypoxia
MIDDLE CEREBRAL A. <p5
CPR <p5
Centralization
Increment placental impedance
www.medicinafetalbarcelona.org/
FETAL DETERIORATION IN PLACENTAL INSUFFICIENCY EARLY VS LATE IUGR (>34s)
PLACENTAL DISEASE DECOMPENSATED HYPOXIA SERIOUS INJURYDEATH
growth
UMBILICAL A. >p95
CTG / BPP ABNORMAL
Placental injury <30%
mild hypoxiano cardiovascular adaptation
minimal tolerance to hypoxia
MIDDLE CEREBRAL A. <p5
CPR <p5
Centralization
Increment placental impedance
www.medicinafetalbarcelona.org/
FETAL DETERIORATION IN PLACENTAL INSUFFICIENCY EARLY VS LATE IUGR (>34s)
PLACENTAL DISEASE DECOMPENSATED HYPOXIA SERIOUS INJURYDEATH
growth
UMBILICAL A. >p95
CTG / BPP ABNORMAL
Placental injury <30%
mild hypoxiano cardiovascular adaptation
minimal tolerance to hypoxia
MIDDLE CEREBRAL A. <p5
CPR <p5
UTERINE A. >p95
Centralization
Increment placental impedance
www.medicinafetalbarcelona.org/
FETAL DETERIORATION IN PLACENTAL INSUFFICIENCY EARLY VS LATE IUGR (>34s)
PLACENTAL DISEASE DECOMPENSATED HYPOXIA SERIOUS INJURYDEATH
growth
UMBILICAL A. >p95
CTG / BPP ABNORMAL
Placental injury <30%
mild hypoxiano cardiovascular adaptation
minimal tolerance to hypoxia
MIDDLE CEREBRAL A. <p5
CPR <p5
UTERINE A. >p95
Ao ISTHMUS >p95
Centralization
Increment placental impedance
www.fetalmedicinebarcelona.org/
IUGR
SGA?
20 30 4025 35
0
3
6 %
IUGR= low CPR or high UtA or EFW<p3 or low PlGF
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.
32w @diagnosis
www.medicinafetalbarcelona.org/
1. Identify small fetus
2. FGR vs. SGA
3. Early vs. Late
4. Stage-based management protocol
www.medicinafetalbarcelona.org/
IUGR = abnormal CPR or UtA or EFW<p3
Savchev 2013
www.medicinafetalbarcelona.org/
IUGR = abnormal CPR or UtA or EFW<p3
Savchev 2013
www.medicinafetalbarcelona.org/
IUGR = abnormal CPR or UtA or EFW<p3
Savchev 2013
www.medicinafetalbarcelona.org/
IUGR = abnormal CPR or UtA or EFW<p3
Savchev 2013
www.medicinafetalbarcelona.org/
IUGR = abnormal CPR or UtA or EFW<p3
Savchev 2013
Red Line EARLY IUGRRed Line LATE IUGR
www.fetalmedicinebarcelona.org/
RATIONALE FOR A STAGE-BASED APPROACH TO THE MANAGEMENT OF FGR
PLACENTAL DISEASE HYPOXIA ACIDOSIS SERIOUS INJURY DEATH
cardiac ischemiaDiastolic failure
Systolic cardiac failure
Centralization
Increment placental impedance
VIVIIIIIStage fetal deterioration
HIGHMODERATELOWRisks of prematurity
Red Line EARLY IUGRRed Line LATE IUGR
www.fetalmedicinebarcelona.org/
RATIONALE FOR A STAGE-BASED APPROACH TO THE MANAGEMENT OF FGR
PLACENTAL DISEASE HYPOXIA ACIDOSIS SERIOUS INJURY DEATH
cardiac ischemiaDiastolic failure
Systolic cardiac failure
Centralization
Increment placental impedance
cCTG: reduced STV
VIVIIIIIStage fetal deterioration
HIGHMODERATELOWRisks of prematurity
Red Line EARLY IUGRRed Line LATE IUGR
www.fetalmedicinebarcelona.org/
RATIONALE FOR A STAGE-BASED APPROACH TO THE MANAGEMENT OF FGR
PLACENTAL DISEASE HYPOXIA ACIDOSIS SERIOUS INJURY DEATH
cardiac ischemiaDiastolic failure
Systolic cardiac failure
Centralization
Increment placental impedance
cCTG: reduced STV
Diagnostic/chronic markersEarly and Late IUGR
VIVIIIIIStage fetal deterioration
HIGHMODERATELOWRisks of prematurity
Red Line EARLY IUGRRed Line LATE IUGR
www.fetalmedicinebarcelona.org/
RATIONALE FOR A STAGE-BASED APPROACH TO THE MANAGEMENT OF FGR
PLACENTAL DISEASE HYPOXIA ACIDOSIS SERIOUS INJURY DEATH
cardiac ischemiaDiastolic failure
Systolic cardiac failure
Centralization
Increment placental impedance
cCTG: reduced STV
Diagnostic/chronic markersEarly and Late IUGR
Prognostic/Acute markersEarly IUGR
VIVIIIIIStage fetal deterioration
HIGHMODERATELOWRisks of prematurity
www.medicinafetalbarcelona.org/
Protocolo CIR Primer paso: si todo N = PEG
I Doppler normal pero PFE<p3
II 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
CPR<p5
Ut A >p95
MCA<p5
I Doppler normal pero PFE<p3
II 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
CPR<p5
Ut A >p95
MCA<p5
I Doppler normal pero PFE<p3
II Aumento resistencia placentaria o redistribución inicial
III Aumento grave resistencia y/o redistribución grave
IV Alteración hemodinámica grave
V Alto riesgo de muerte
AEDV AoI >p95
www.medicinafetalbarcelona.org/
Protocolo CIR Primer paso: si todo N = PEG
CPR<p5
Ut A >p95
MCA<p5
REDV DV >p95 UVpuls
I Doppler normal pero PFE<p3
II Aumento resistencia placentaria o redistribución inicial
III Aumento grave resistencia y/o redistribución grave
IV Alteración hemodinámica grave
V Alto riesgo de muerte
AEDV AoI >p95
www.medicinafetalbarcelona.org/
Protocolo CIR Primer paso: si todo N = PEG
CPR<p5
Ut A >p95
MCA<p5
DV (a rev)
CGT decelerations of reduced short-term
variability
REDV DV >p95 UVpuls
I Doppler normal pero PFE<p3
II Aumento resistencia placentaria o redistribución inicial
III Aumento grave resistencia y/o redistribución grave
IV Alteración hemodinámica grave
V Alto riesgo de muerte
AEDV AoI >p95
Mort. >90% 50% <10%Morb. >90% 50%
www.medicinafetalbarcelona.org/
<26w 26-28 28-32 32-34 34-37
DeliveryDV(a-‐)
cCTG abn.CTG dec.
DV>p95UV puls REDV
(a) AEDV(b) AoI>95 CPR>p95
UtA>p95MCA<p5
EFW<p3
Stage V IV III II I
Mode CS CS CS or LI LI
IUGRManagement protocol according to severity stages
Follow-‐up Daily 1-‐2 d 2/w 1/w
Mort. >90% 50% <10%Morb. >90% 50%
www.medicinafetalbarcelona.org/
<26w 26-28 28-32 32-34 34-37
DeliveryDV(a-‐)
cCTG abn.CTG dec.
DV>p95UV puls REDV
(a) AEDV(b) AoI>95 CPR>p95
UtA>p95MCA<p5
EFW<p3
Stage V IV III II I
Mode CS CS CS or LI LI
IUGRManagement protocol according to severity stages
Follow-‐up Daily 1-‐2 d 2/w 1/w
Mort. >90% 50% <10%Morb. >90% 50%
www.medicinafetalbarcelona.org/
<26w 26-28 28-32 32-34 34-37
DeliveryDV(a-‐)
cCTG abn.CTG dec.
DV>p95UV puls REDV
(a) AEDV(b) AoI>95 CPR>p95
UtA>p95MCA<p5
EFW<p3
Stage V IV III II I
Mode CS CS CS or LI LI
IUGRManagement protocol according to severity stages
Follow-‐up Daily 1-‐2 d 2/w 1/w
Mort. >90% 50% <10%Morb. >90% 50%
www.medicinafetalbarcelona.org/
<26w 26-28 28-32 32-34 34-37
DeliveryDV(a-‐)
cCTG abn.CTG dec.
DV>p95UV puls REDV
(a) AEDV(b) AoI>95 CPR>p95
UtA>p95MCA<p5
EFW<p3
Stage V IV III II I
Mode CS CS CS or LI LI
IUGRManagement protocol according to severity stages
Follow-‐up Daily 1-‐2 d 2/w 1/w
www.medicinafetalbarcelona.org/
www.medicinafetalbarcelona.org/
The main goal in FGR is identification
www.medicinafetalbarcelona.org/
The main goal in FGR is identification
Small fetus (EFW<p10) must be divided in:
www.medicinafetalbarcelona.org/
The main goal in FGR is identification
Small fetus (EFW<p10) must be divided in: FGR (placenta, poor perinatal and long-term outcome)
www.medicinafetalbarcelona.org/
The main goal in FGR is identification
Small fetus (EFW<p10) must be divided in: FGR (placenta, poor perinatal and long-term outcome)
SGA (we don’t know, perinatal outcome N, poor long term)
www.medicinafetalbarcelona.org/
The main goal in FGR is identification
Small fetus (EFW<p10) must be divided in: FGR (placenta, poor perinatal and long-term outcome)
SGA (we don’t know, perinatal outcome N, poor long term)
Early and late-onset FGR (GA 32s) represent two distinct phenotypes of the same disease
www.medicinafetalbarcelona.org/
The main goal in FGR is identification
Small fetus (EFW<p10) must be divided in: FGR (placenta, poor perinatal and long-term outcome)
SGA (we don’t know, perinatal outcome N, poor long term)
Early and late-onset FGR (GA 32s) represent two distinct phenotypes of the same disease
Clinically, a single stage-based protocol allows optimizing decisions in all cases
www.medicinafetalbarcelona.org/
www.fetalmedicinebarcelona.org
