11

2nd International Conference on Fetal Growth

September 19-21st, 2013

Ahmet A. Baschat, MD

Professor, Director of Maternal-Fetal Medicine and Section of Fetal Therapy

University of Maryland School of Medicine

Management of early onset fetal growth restrictionManagement of early onset fetal growth restriction

Proposed origins of damage

Hypoxemia

Acidemia

neurologic

Damage

StillbirthJames al. al, Soothill et al., Arduini et al., Senat et al., Harrington et al., Bilardo et al., Hecher et al,, Ribbert et al., Ferrazzi et al., Baschat et al., Cosmi et al., Divon et al.

abnormalUmbilical

Brain sparing

abnormalvenousDoppler

abnormalcCTG

abnormalbiophysical

Delivery !

If this were true…� FGR fetuses should be normal before deterioration

� Deterioration should be associated with worse neurodevelopmental outcome

� Early intervention should make a difference

Am J Obstet Gynecol 2011

Determinants of outcome

Baschat 2012

NEURODEVELOPMENT

ACIDEMIA

STILLBIRTH MORTALITY

MORBIDITY

FETAL RISK NEONATAL RISK

1st consideration: Gestational age

24 25 26 27 28 29 30 31 32Gestational week

0

10

20

30

40

50

60

70

80

90

100

Perc

ent

Baschat et al, Obstet Gynecol., 2007

Survival Intact

+ 2% / Day in utero + 1% / Day in utero

DV Doppler only has an independent impact on Survival

from 28 weeks on

BW < 600

GA <27.0

(r2=0.48)

22

547 singleton / Twins - 24-36 GA

Unsure about delivery timing

Immediate delivery

Deliver when no longer in doubtBJOG 2003

+4.9 days(*6.9 > 31 SSW)

<0.05C-section 91% 76%FDIU 2 9 <0.05neonatal Death 27 18 0.06

Perinatal Mortality 29 27 n.s.

817Prematurity-related <0.05 <30 weeks

Oxford Vermont Network

(Am J Obstet Gynecol 2000)

IUGR & AGA = equal benefit from steroids

19 759 VLBW infants – IUGR vs. AGA

RDS 1.19 (1.03 – 1.36)NEC 1.27 (1.09 – 1.57)IVH 1.13 (0.99 – 1.29)Neonatal death 2.77 (2.31 – 3.33)

Comparing Steroid benefits in preterm IUGR & AGA

+1% survival / DFetal deterioration has independent impact. Wait, but excellent monitoring necessary

+2% survival / Dif in doubt wait

Excellent monitoring necessary

Previable for FGR unless EFW >500 or GA is >26 wks.

Steroids decrease RDS, NEC & mortality

24 26 28 30 3834

Delay to gain

viability

Delay to gain survival

Delay to improve morbidity

Delay for steroids

Maternal indications, e.g. pre-eclampsia

Abnormal biophysical profile score

Kahn et al., Obstet Gynecol 2003; Trudell et al., Am J Obstet Gynecol 2013; DIGITAT BMJ 2010; DIGITAT Am J Obstet Gynecol 2012; Baschat et al., Obstet Gynecol 2007; GRIT BJOG 2003; Bersntein et al., Am J Obstet Gynecol 200l

2nd consideration: Fetal deterioration

When should a small fetus be delivered?

When should a small fetus be delivered?

� When the baby is better off outside the uterus

� Fetal risks

� Hypoxemia

� Acidemia

� Organ damage (brain damage)

� Stillbirth

� Neonatal risks

� Poor transition

� Prematurity & complications

� Organ damage (brain damage)

� Neonatal death

-10

Δ p

H

0

-2

-4

-6

-8

Non-reactive

CTG STV <3.5

Biophysical parameters Doppler parameters

Akalin-Sel et al., Arduini et al., Bilardo et al., Guzman et al,, Hecher et al,, Nicolaides et al., Ribbert et al., Rizzo et al., Soothill et al., Visser et al., Weiner et al. Turan et al., Kiserud et al., Gudmundsson et al.

pH < 7.20 pH < 7.10

Absent breathing

Absent tone & movement

Oligohydramnios(<2 cm)

Abnormal UA Brain

sparing

Abnormal DV

abnormal cCTG and DV comparable pH range

Biophysical parametershave closer relation to pH

33

Ultrasound Obstet Gynecol 2007; 30: 750-56

““““Venous Doppler provides best prediction, cCTG best if combined with venous Doppler or if substituted for the traditional NST in the BPS””””

Combination of tests improves prediction

Acidemia Stillbirth0

10

20

30

40

50

60

70

80

90

100

Abnormal venous Doppler

Abnormal biophysical parameters

Both abnormal

Perc

ent

91%

78%

0

10

20

30

40

50

60

70

80

90

100

Perc

ent

StillbirthAcidemia

false positive rate

17%23%

Baschat et al, Am J Obstet Gynecol., 2008, Turan et al OUG, 2011

Sensitivity

Sensitivity & Specificity = 179

N = 1024

4 – 6 weeks

Deliver at any GA

Stillbirth

hypoxemia

acidemia

compensated

Abnl BPP

Early onset

28 weeks

32 weeks

34 weeks

3rd consideration: Monitoring interval

What do you need to do when you are not yet planning to

deliver?

What do you need to do when you are not yet planning to

deliver?� See the patient again in an appropriate

interval

� Monitoring risks

� Hypoxemia

� Acidemia

� Organ damage

� Stillbirth

If you don’’’’t see the patient frequently enough

AcidemiaHypoxemia Stillbirth

Delivery(+/- Steroids)

Deliver at any GA

Stillbirth

hypoxemia

acidemia

compensated

Abnl BPP

Early onset

daily

weekly

2-3 x weekly

44

High delivery threshold

UA MCA DV UV BPP

UA MCA DV UV BPP

4 Weeks

6 Weeks

Severity of placental dysfunction determines 2 rates of progression

Shorten monitoring interval forUA-AREDV, DV-RAV, Oligo

Shorten monitoring interval forUA-AREDV, DV-PI, Oligo.

Gradually decreasing delivery threshold

DV - RAV DV > 3SD UA-REDV UA-AEDV MCA

STV < 3.5

STV < 4 msec STV<5 ms ?

DV RAV & pulsatile UV

STV < 3.5 & decelerations

24 26 28 32 3430

Periviability>50% Mortality

< 50% Intactsurvival

+2 % Survival / day in utero

Worse outcome with fetal decompensation

38

+1 % Survival / day in utero Increased prospective stillbirth

rate

Administer steroids for anticipated delivery

Deliver for maternal indications or biophysical profile < 6