cir precoz y tardÍo - medicinafetalbarcelona · cir precoz y tardÍo eduard gratacos servicio de...

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CIR PRECOZ Y TARDÍOEduard Gratacos

Servicio de Medicina MaternofetalHospital Clinic y Hospital Sant Joan de Deu - Universidad de Barcelona

www.fetalmedicinebarcelona.org

martes 18 de junio de 13

http://www.fetalmedicinebarcelona.org


http://www.medicinafetal

http://www.medicinafetal

www.medicinafetalbarcelona.org/

1. CIR vs. PEG

2. Precoz vs. Tardío

3. Implicación en el manejo clínico



Savchev 2013



The discovery of UA and hemodynamics of IUGR

Savchev 2013



Constitutionally small Placental insufficiency Extrinsic cause

Primary fetal defect


IUGR = abnormal UA Doppler

Savchev 2013





SGA IUGR



Savchev 2013





SGA IUGR



20 30 4025 35 Savchev 2013





SGA IUGR



20 30 4025 35

0

N cases

N cases

Savchev 2013





SGA IUGR



20 30 4025 35

0

N cases

N cases

UA Doppler +(EARLY-ONSET)

Savchev 2013





SGA IUGR



20 30 4025 35

0

N cases

N cases

UA Doppler +(EARLY-ONSET)

UA Doppler N(LATE-ONSET)

Savchev 2013



e<p95

SGA

SGA = constitutionally small?



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




Significant increase in the risk of adverse perinatal outcome

Hershkovitz et al. Ultrasound Obstet Gynecol 2000



e<p95

SGA


Significant increase in the risk of adverse neurodevelopment

Eixarch et al. Ultrasound Obstet Gynecol 2008





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



Neurobehavioral performance of term SGA newborns

* **

**

* p <0.05Adjusted for GA, maternal age, socioeconomic status and smoking

N=120 SGA vs

100 AGA



Neurobehavioral performance of term SGA newborns

* **

**

* p <0.05Adjusted for GA, maternal age, socioeconomic status and smoking

Satchev, 2012Geva 2008

Figueras 2008Eixarch 2010

N=120 SGA vs

100 AGA

* * *

Bay

ley

Sco

re

20

40

60

80

100

120

cognitive language motor socio-emotional adaptivebehavior

* * *



control IUGR

Crispi 2010

Cardiovascular programming in SGA / late-IUGR



control IUGR

Crispi 2010

Cardiovascular programming in SGA / late-IUGRFetuses EFW<p10 evaluated at 5 years

Classified by CPR, p3 and UtA Doppler:•All normal: SGA•Any abnormal: late-IUGR



control IUGR

Crispi 2012

Crispi 2010

Cardiovascular programming in SGA / late-IUGRFetuses EFW<p10 evaluated at 5 years

Classified by CPR, p3 and UtA Doppler:•All normal: SGA•Any abnormal: late-IUGR



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 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

Classification of stillbirth by relevant condition at birth (ReCoDe): population-based cohort studyGardosi et al. BMJ 2005, 2010

N=2625 stillbirths

FGR as relevant condition identified in 43-60%



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







Centralization


growth

MIDDLE CEREBRAL A.

UMBILICAL A.

DUCTUS VENOSUS

CTG / BPP ABNORMAL

Placental injury <30%







Centralization


growth

MIDDLE CEREBRAL A.

UMBILICAL A.

DUCTUS VENOSUS

CTG / BPP ABNORMAL


mild hypoxiano cardiovascular adaptation





Centralization


growth

MIDDLE CEREBRAL A.

UMBILICAL A.

CTG / BPP ABNORMAL







Centralization


growth

MIDDLE CEREBRAL A.

UMBILICAL A.

CTG / BPP ABNORMAL



minimal tolerance to hypoxia




PLACENTAL DISEASE DECOMPENSATED HYPOXIA SERIOUS INJURYDEATH

Centralization


growth

MIDDLE CEREBRAL A.

UMBILICAL A.

CTG / BPP ABNORMAL



minimal tolerance to hypoxia



Distribution of cases when IUGR = abnormal UA Doppler

Savchev 2013



Distribution of cases when IUGR = abnormal CPR or UtA or EFW<p3

Savchev 2013



1. CIR vs. PEG





IUGR

SGA?

20 30 4025 35

0

3

6 %

IUGR= low CPR or high UtA or EFW<p3 or low PlGF





IUGR

SGA?

20 30 4025 35

0

3

6 %


32w @diagnosis





IUGR

SGA?

20 30 4025 35

0

3

6 %


EARLY IUGR (1%) LATE IUGR (5-7%)

32w @diagnosis





IUGR

SGA?

20 30 4025 35

0

3

6 %



PROBLEM: MANAGEMENT PROBLEM: DIAGNOSIS

32w @diagnosis





IUGR

SGA?

20 30 4025 35

0

3

6 %




Placental disease: high (UA+, PE high) Placental disease: low (UA-, PE low)

32w @diagnosis





IUGR

SGA?

20 30 4025 35

0

3

6 %





Hypoxia ++: systemic CV adaptation Hypoxia +/-: central CV adaptation

32w @diagnosis





IUGR

SGA?

20 30 4025 35

0

3

6 %






Tolerance to hypoxia. Natural history Low tolerance: no natural history

32w @diagnosis





IUGR

SGA?

20 30 4025 35

0

3

6 %






Tolerance to hypoxia. Natural history Low tolerance: no natural history

High mortality and morbidity Low mortality but poor long outcome.

32w @diagnosis




Perinatal >90% 30-‐40% <10%Mortality


<26 26-28 >28

Baschat 2003Hecher 2003 Grivell 2010Cruz-‐Lemini 2012

Early-onset IUGRPROBLEM #1: MORTALITY






<26 26-28 >28



DVa (rev)

Yes No

60%

19%






<26 26-28 >28



DVa (rev)

Yes No

60%

19%

cCTG-‐STV<3 ms

Pathological CGT






<26 26-28 >28



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


<29 29-32 >32.0

Fouron 2004Del Rio 2008Cruz-‐MarQnez 2012

Early-onset IUGRPROBLEM #2: (NEUROLOGICAL) MORBIDITY




Neurologic >90% 30-‐40% <10%Morbidity


<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





• 5-7% newborns• detection < 50%• > 40% late pregnancy IUFD• Neurological, cardiovascular and

metabolic impact• diagnosis SGA vs. Late-IUGR

IUGR

SGA?

20 30 4025 35

0

3

3%







IUGR

SGA?

20 30 4025 35

0

3

3%

CLINICAL PROBLEMS

# 1: DIAGNOSISdetection <50%

# 2: POOR PERINATAL OUTCOME (∼50%)• A “Late-IUGR subset” with poorer perinatal

outcome can be identified

# 3: LONG TERM OUTCOME (∼50%)Fetal programming

No means to select high risk groups







IUGR

SGA?

20 30 4025 35

0

3

3%

CLINICAL PROBLEMS






signs adaptation/

severity

yes

no







IUGR

SGA?

20 30 4025 35

0

3

3%

CLINICAL PROBLEMS






poorer

perinatal outcome

normal

signs adaptation/

severity

yes

no




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


0%

10%

20%

30%

40%

50%

Controls All normal Any abnormal



Figueras 2012


UtA >p95


0%

10%

20%

30%

40%

50%

8%




Figueras 2012


UtA >p95


0%

10%

20%

30%

40%

50%

8%11%




Figueras 2012


UtA >p95


0%

10%

20%

30%

40%

50%

8%11%

40%


%



Figueras 2012


www.medicinafetalbarcelona.org/docencia

Late-onset intrauterine growth restriction vs. small-for-gestational age(submitted)

Figueras 2012




SGA

40% of late-SGA with 11 % risk (14% of all adverse outcomes)

Figueras 2012




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



1. CIR vs. PEG





IUGR = abnormal CPR or UtA or EFW<p3

Savchev 2013



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






CPR<p5

Ut A >p95

MCA<p5











CPR<p5

Ut A >p95

MCA<p5






AEDV AoI >p95






CPR<p5

Ut A >p95

MCA<p5

REDV DV >p95 UVpuls






AEDV AoI >p95






CPR<p5

Ut A >p95

MCA<p5

DV (a rev)

CGT decelerations of reduced short-term

variability

REDV DV >p95 UVpuls






AEDV AoI >p95




Mort. >90% 50% <10%Morb. >90% 50%


<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

Early-onset IUGRManagement protocol according to severity stages

Follow-‐up Daily 1-‐2 d 2/w 1/w





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



Prediction of cesarean section for fetal distress after labor induction in term SGA fetuses with Doppler signs of brain sparing (N=202)

Cruz et al, 2010

(OVERALL RISK OF CS AFTER INDUCTION 80 %)

0"

10"

20"

30"

40"

50"

60"

70"

Cesarean"sec1on"for"distress"

Neonatal"acidosis"

AGA"

SGA"normal"MCA"

SGA"abnormal"MCA"


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