actualizaciÓn en crecimiento intrauterino restringido
TRANSCRIPT
www.fetalmedicinebarcelona.org/
ACTUALIZACIÓN EN CRECIMIENTO INTRAUTERINO
RESTRINGIDOEduard Gratacos
Servicio de Medicina MaternofetalHospital Clinic y Hospital Sant Joan de Deu - Universidad de Barcelona
www.fetalmedicinebarcelona.org
www.medicinafetalbarcelona.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/
Constitutionally small Placental insufficiency Extrinsic cause
Primary fetal defect
The discovery of UA and hemodynamics of IUGR
IUGR = abnormal UA Doppler
Savchev 2013
www.medicinafetalbarcelona.org/
Constitutionally small Placental insufficiency Extrinsic cause
Primary fetal defect
SGA IUGR
The discovery of UA and hemodynamics of IUGR
IUGR = abnormal UA Doppler
Savchev 2013
www.medicinafetalbarcelona.org/
Constitutionally small Placental insufficiency Extrinsic cause
Primary fetal defect
SGA IUGR
The discovery of UA and hemodynamics of IUGR
IUGR = abnormal UA Doppler
20 30 4025 35 Savchev 2013
www.medicinafetalbarcelona.org/
Constitutionally small Placental insufficiency Extrinsic cause
Primary fetal defect
SGA IUGR
The discovery of UA and hemodynamics of IUGR
IUGR = abnormal UA Doppler
20 30 4025 35
0
N cases
N cases
Savchev 2013
www.medicinafetalbarcelona.org/
Constitutionally small Placental insufficiency Extrinsic cause
Primary fetal defect
SGA IUGR
The discovery of UA and hemodynamics of IUGR
IUGR = abnormal UA Doppler
20 30 4025 35
0
N cases
N cases
Savchev 2013
www.medicinafetalbarcelona.org/
Constitutionally small Placental insufficiency Extrinsic cause
Primary fetal defect
SGA IUGR
The discovery of UA and hemodynamics of IUGR
IUGR = abnormal UA Doppler
20 30 4025 35
0
N cases
N cases
UA Doppler +(EARLY-ONSET)
Savchev 2013
www.medicinafetalbarcelona.org/
Constitutionally small Placental insufficiency Extrinsic cause
Primary fetal defect
SGA IUGR
The discovery of UA and hemodynamics of IUGR
IUGR = 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/
e<p95
SGA
SGA = constitutionally small?
www.medicinafetalbarcelona.org/
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
e<p95
SGA
SGA = constitutionally small?
www.medicinafetalbarcelona.org/
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
e<p95
SGA
SGA = constitutionally small?
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/
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. Identificar feto pequeño
2. CIR vs. PEG
3. Precoz vs. Tardío
4. Implicación en el manejo clínico
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.
CPR / UMBILICAL A.
CTG ABNORMAL
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.
CPR / UMBILICAL A.
DUCTUS VENOSUS
CTG ABNORMAL
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.
CPR / UMBILICAL A.
DUCTUS VENOSUS
CTG ABNORMAL
UTERINE A.
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.
CPR / UMBILICAL A.
DUCTUS VENOSUS
CTG ABNORMAL
UTERINE A.
cCTG: reduced short-term variability
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.
CPR / UMBILICAL A.
DUCTUS VENOSUS
CTG ABNORMAL
UTERINE A.
cCTG: reduced short-term variability
Ao ISTHMUS
Perinatal >90% 30-‐40% <10%Mortality
www.medicinafetalbarcelona.org/
<26 26-28 >28
Baschat 2003Hecher 2003 Grivell 2010Cruz-‐Lemini 2012
Early-onset IUGRPROBLEM #1: MORTALITY
Perinatal >90% 30-‐40% <10%Mortality
www.medicinafetalbarcelona.org/
<26 26-28 >28
Baschat 2003Hecher 2003 Grivell 2010Cruz-‐Lemini 2012
Early-onset IUGRPROBLEM #1: MORTALITY
DVa (rev)
Yes No
60%
19%
Perinatal >90% 30-‐40% <10%Mortality
www.medicinafetalbarcelona.org/
<26 26-28 >28
Baschat 2003Hecher 2003 Grivell 2010Cruz-‐Lemini 2012
Early-onset IUGRPROBLEM #1: MORTALITY
DVa (rev)
Yes No
60%
19%
cCTG-‐STV<3 ms
Pathological CGT
Perinatal >90% 30-‐40% <10%Mortality
www.medicinafetalbarcelona.org/
<26 26-28 >28
Baschat 2003Hecher 2003 Grivell 2010Cruz-‐Lemini 2012
Early-onset IUGRPROBLEM #1: MORTALITY
DVa (rev)
Yes No
60%
19%
cCTG-‐STV<3 ms
Pathological CGT
BPPIUFD 23% in BPP=6 and 11% in BPP=8
Poor correlation with DVa(rev)Cochrane: poor contribution to prediction
Baschat 2007, Kafur 2008, Lalor 2010, Crispi 2009
Neurologic >90% 30-‐40% <10%Morbidity
www.medicinafetalbarcelona.org/
<29 29-32 >32.0
Fouron 2004Del Rio 2008Cruz-‐MarQnez 2012
Early-onset IUGRPROBLEM #2: (NEUROLOGICAL) MORBIDITY
Neurologic >90% 30-‐40% <10%Morbidity
www.medicinafetalbarcelona.org/
<29 29-32 >32.0
Fouron 2004Del Rio 2008Cruz-‐MarQnez 2012
Early-onset IUGRPROBLEM #2: (NEUROLOGICAL) MORBIDITY
0
15
30
45
60
(%)
ControlsIUGR antegrade AoIIUGR retrograde AoI
ControlsIUGR DV<5 z-scoreIUGR DV>5 z-score
**
Brain US anomalies in 30w IUGR
Neurologic >90% 30-‐40% <10%Morbidity
www.medicinafetalbarcelona.org/
<29 29-32 >32.0
Fouron 2004Del Rio 2008Cruz-‐MarQnez 2012
Early-onset IUGRPROBLEM #2: (NEUROLOGICAL) MORBIDITY
0
15
30
45
60
(%)
ControlsIUGR antegrade AoIIUGR retrograde AoI
ControlsIUGR DV<5 z-scoreIUGR DV>5 z-score
**
Brain US anomalies in 30w IUGR
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
Centralization
Increment placental impedance
growth
MIDDLE CEREBRAL A.
UMBILICAL A.
DUCTUS VENOSUS
CTG / BPP ABNORMAL
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
Centralization
Increment placental impedance
growth
MIDDLE CEREBRAL A.
UMBILICAL A.
DUCTUS VENOSUS
CTG / BPP ABNORMAL
Placental injury <30%
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
Centralization
Increment placental impedance
growth
MIDDLE CEREBRAL A.
UMBILICAL A.
DUCTUS VENOSUS
CTG / BPP ABNORMAL
Placental injury <30%
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
Centralization
Increment placental impedance
growth
MIDDLE CEREBRAL A.
UMBILICAL A.
DUCTUS VENOSUS
CTG / BPP ABNORMAL
Placental injury <30%
mild hypoxiano cardiovascular adaptation
www.medicinafetalbarcelona.org/
FETAL DETERIORATION IN PLACENTAL INSUFFICIENCY EARLY VS LATE IUGR (>34s)
PLACENTAL DISEASE COMPENSATED HYPOXIA DECOMPENSATED HYPOXIA SERIOUS INJURYDEATH
Centralization
Increment placental impedance
growth
MIDDLE CEREBRAL A.
UMBILICAL A.
CTG / BPP ABNORMAL
Placental injury <30%
mild hypoxiano cardiovascular adaptation
www.medicinafetalbarcelona.org/
FETAL DETERIORATION IN PLACENTAL INSUFFICIENCY EARLY VS LATE IUGR (>34s)
PLACENTAL DISEASE COMPENSATED HYPOXIA DECOMPENSATED HYPOXIA SERIOUS INJURYDEATH
Centralization
Increment placental impedance
growth
MIDDLE CEREBRAL A.
UMBILICAL A.
CTG / BPP ABNORMAL
Placental injury <30%
mild hypoxiano cardiovascular adaptation
minimal tolerance to hypoxia
www.medicinafetalbarcelona.org/
FETAL DETERIORATION IN PLACENTAL INSUFFICIENCY EARLY VS LATE IUGR (>34s)
PLACENTAL DISEASE DECOMPENSATED HYPOXIA SERIOUS INJURYDEATH
Centralization
Increment placental impedance
growth
MIDDLE CEREBRAL A.
UMBILICAL A.
CTG / BPP ABNORMAL
Placental injury <30%
mild hypoxiano cardiovascular adaptation
minimal tolerance to hypoxia
www.medicinafetalbarcelona.org/docencia
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)
SGA
40% of late-SGA with 11 % risk (14% of all adverse outcomes)
Figueras 2012
www.medicinafetalbarcelona.org/docencia
Late-onset intrauterine growth restriction vs. small-for-gestational age(submitted)
Late-IUGR
SGA
60% of late-SGA with 40% risk (86% of all adverse outcomes)
40% of late-SGA with 11 % risk (14% of all adverse outcomes)
Figueras 2012
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 = abnormal CPR or UtA or EFW<p3
Savchev 2013
www.fetalmedicinebarcelona.org/
FETAL DETERIORATION IN IUGRPLACENTAL DISEASE COMPENSATED HYPOXIA DECOMPENSATED HYPOXIA SERIOUS INJURY
DEATH
cardiac ischemiaDiastolic failure
Systolic cardiac failure
Centralization
Increment placental impedance
www.fetalmedicinebarcelona.org/
FETAL DETERIORATION IN IUGRPLACENTAL DISEASE COMPENSATED HYPOXIA DECOMPENSATED HYPOXIA SERIOUS INJURY
DEATH
cardiac ischemiaDiastolic failure
Systolic cardiac failure
Centralization
Increment placental impedance
cCTG: reduced STV
www.fetalmedicinebarcelona.org/
FETAL DETERIORATION IN IUGRPLACENTAL DISEASE COMPENSATED HYPOXIA DECOMPENSATED HYPOXIA SERIOUS INJURY
DEATH
cardiac ischemiaDiastolic failure
Systolic cardiac failure
Centralization
Increment placental impedance
cCTG: reduced STV
Diagnostic/chronic markersEarly and Late IUGR
www.fetalmedicinebarcelona.org/
FETAL DETERIORATION IN IUGRPLACENTAL DISEASE COMPENSATED HYPOXIA DECOMPENSATED HYPOXIA 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
www.fetalmedicinebarcelona.org/
FETAL DETERIORATION IN IUGRPLACENTAL DISEASE COMPENSATED HYPOXIA DECOMPENSATED HYPOXIA SERIOUS INJURY
DEATH
cardiac ischemiaDiastolic failure
Systolic cardiac failure
Centralization
Increment placental impedance
cCTG: reduced STV
HIGHMODERATELOW
Risks of prematurity
Diagnostic/chronic markersEarly and Late IUGR
Prognostic/Acute markersEarly IUGR
www.fetalmedicinebarcelona.org/
FETAL DETERIORATION IN IUGRPLACENTAL DISEASE COMPENSATED HYPOXIA DECOMPENSATED HYPOXIA SERIOUS INJURY
DEATH
cardiac ischemiaDiastolic failure
Systolic cardiac failure
Centralization
Increment placental impedance
cCTG: reduced STV
HIGHMODERATELOW
Risks of prematurity
VIVIIIII
Diagnostic/chronic markersEarly and Late IUGR
Prognostic/Acute markersEarly IUGR
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.
(a) 28 wDV>p95 / UV puls
(b) 30 wREDV
(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.
(a) 28 wDV>p95 / UV puls
(b) 30 wREDV
(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.
(a) 28 wDV>p95 / UV puls
(b) 30 wREDV
(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.
(a) 28 wDV>p95 / UV puls
(b) 30 wREDV
(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/
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