DIAGNOSIS OF IUGR in pregnancycriteria in India.pptx

Iugr

1. DIAGNOSIS OF IUGR

2. HISTORY Corre c t ges t at i onal age Histo r y of Prev i ous IUGR baby Histo r y of d i sorders a f fec t ing placen t al funct i on Obste t r i c hi s to r y Dieta r y hi s to r y Drug / Radia t ion exposure / Addict i on Fam i ly hi s to r y Socioecono m ic s t atus

3. EXAMINATION Ge n er a l e x ami n ation Systemic e x ami n ation Obstetric a l ex a minatio n - S F H /AG After 20 w k s S F H corr e spo n ds to the no. of w k s. of gest a t i o n . (JAMES) Betwe e n 1 8 - 3 w k s. S F H coincides within 2 w ks of GA & a l a g of 2 - 3c m s. Den o t e s gr o wth re s tr i c t ion (WILL I AMS) S F H incr e a s es by 1c m / wk b / w 1 4 - 3 2 w k s. A l a g o f > 4 w k s de n otes m o d er a te IUGR & > 6 w ks de n otes s e vere IUG R . (I A N DON A LD’ S ) AG incr e a s es by 1 inc h / w k . af t er 30 w k s. It is 3 0i n ch @ 30 w k s

4. INVESTIGATION Rou t in e ANC in vest i gati o ns U L TR A SOUND: Mo st u s eful in v . G e station age deter m inatio n - p r ior to 24 wks , b ut m ost a c curate @ 1 0- 12 wks C R L is the m o st a c curate para m ete r (WILLIA M S) The r e is an er r or of around: 7 d ays in 1 s t tri m ester 10 - 1 1 days in 2 nd tr i m ester 21 days in 3 rd tr i m ester ( J A M ES) Det e r m in ation of EF W : AC & E FW D e ter m inatio n of m ul t ip l e gestation Det e r m in ation of Fetal w ellbei n g

5. Det e rmin a ti o n of Con g e n ital a n om a lies: @ 1 6 -20 wks of g e station (WILLIAM S ) Det e rmin a ti o n of pla c e n ta: Assessm e nt of fetal gr o wth: Re p e a t @ 3 2 -34 wks BPD(Bi Parietal Diam e ter ) - Most acc u rate for dating in 2 nd trimester (1 4 -26 w ks) [WIL L IAMS]

6. Proximall y -out e r table, Distal l y -inn e r table @ THE LE V EL OF THALAMUS & C A V U M S E PTUMMEAS U RE D PELLU C I D UM WIL L I A MS 23 r d ED I TION

7. HC(H e ad Circu m fer e nce): More a c c u rate than BPD in Dolic o c e phalic or Bra c h y c e p h al i c head CEPHALIC INDEX: Ratio of BPD to Oc c ipitofr o ntal dia m ete r

8. FL(Fe m ur Len g t h ): Measured @ t h e level per p en d ic u lar to s h a f t exc l u d i n g t h e ep i p h y s is Corr e la t es well wi t h t h e BPD & Ges t at i o n al age A C (Abdominal Circum f erence): Si n g l e be s t pa r a m eter f or de t ect i on of IUGR be c au s e it is rel a ted to t h e l i ver s i ze which re f lec t s f etal g l yc o gen s t or a ge (JAMES) Its se n s i t i v i ty is f ur t her i n c. by ser i al m ea s ur e m en t s at l ea s t 14 da y s ap a rt (JAMES) W e sh o u l d n o t not la b el as gr o wth res t ric t ed f et u s u n le s s AC is f ar be l ow n o r m al or u n l ess o t her pa r a m ete r s co r rel a te. (JAMES)

9. ABDOMINAL CIRCUMFEREN C E

10. TCD( T rans Cere b ellar Diameter): Correlates well with the g e station a g e Relativ e ly sp a red in mild to mod e rate Utero p lac e n t al dy s fu n ction. Upto 25 wks TCD i n cm s . = GA (I A N DO N ALD ’ S)

11. Age independent ratios H C / AC: De c re a ses line a rly from 1 6 -4 wk s . n o rm a ll y . Rati o > 2SD is su g g e stive of IUGR (I A N DONA L D’ S ) FL/ A C: No r mal v a lue = 2 2 + 2% i n sec o nd h a lf of pr eg . Ratio a b o v e 2 3.5% is a b n o rm a l (I A N DON A LD’ S )

12. Det e rmin a ti o n of Am n iotic Fluid V olu m e: T y p e II IUGR c a us e s Ol i g o h y dr a m i nos Am n iotic Fluid In d e x (AFI) = 5 - 1 8 cm s . Maxim u m Liqu o r Poc k et = 2 -8 cm s .

13. Dop p le r eff ect: Change i n the apparent frequency due to relat i ve mo t ion between the source & the observe r . (Doppler probe & R B Cs) When t he sound w ave s t r i kes a moving ta r get, the frequency of s ound w aves ref l ected back is propor t iona t e to the veloc i ty & di r ect i on of mov i ng object. Used to dete r m i ne the volu m e & ra t e of blood f l ow throu g h mate r n a l vesse l s

14. Ty p e s : 1 ) CO N TI N U O US W A VE D O PP L ER: T wo cry s ta l s are u s ed, o n e tra n smits & ot h er rece i ves wave Used in M - m o d e echocar d i o gra p hy 1 ) PU L SE W A VE D O PP L ER: Only o n e cr y s t al t h at T ran s m i ts - wai t -Receive s - wait - T rans m i t s All o ws pr e ci s e ta r ge t i n g & vi s ua l iza t i o n of t h e ve s sel of in t ere s t Have s o f tware t h at d i s p la y s b l o o d f l o w - T owards t ran s d u cer as R E D A way f rom tra n s d uc e r as BLUE

15. An g le of Ins o n a tio n : Betw e en d o p p ler b e am & dir e ction of flow Hig h er the a n gle less e r t he freq u e n cy & more the err o r

16. F r equency chang e r elative to angle o f inso n ati o n

17. T o minimize err o r we use R A TIO S , t o can c el o f f the c os ϴ Arterial Doppler indices S / D R atio : Peak systolic flow(S) End dia s tolic flow( D )

18. PUL S A TILITY INDEX : peak systolic velocity end diastolic velocity RESI S T ANCE INDEX : S -D S Ve n ous D oppler indices

19. COLOUR DOPPLER M A TER N AL COM P ART M E N T Uterine artery FET A L COM P ART M E N T Umbilical artery Middle Cerebral Artery Venous Doppler

20. Uterine artery D oppler:

21. Its main use i s in scree n ing. Early dia s tolic n o tch in the uterine arte r y @ 1 2 -14 wk s . sug g est d e lay e d tro p h o bla s ticinv a sion ( J A M ES) Persiste n ce of n o tch b e y o nd 24 wks co n firms & indi c ates an inc r e a se risk of Pr e -e c lam p si a , P l ac e ntal abr u ption & E arly on s et IUGR. ( J AMES) In c re a se imp e d e n c e of flow in Uterine arte r y @ 1 6 -20 wks was pre d ictive of su p erim p os e d pr e -e c lampsia d e v e lopi n g inw o men with chr o nic h y p e rtension. (WILLIAM S )

22. Umb i lical A R TE R Y DOPPLER

23. Umbilical A. Doppl e r indic e s sh o uld be me a sur e d o n ly after 23 wks (STUD D ) It is us e ful a d jun c t in the ma n a g em e nt of pr e g n ancies c o mplic a ted by feta l -gr o wth restricti o n. ( A CO G - 2008) It is not rec o mme n ded for scr e eni n g of lo w -risk pr e g n ancies or for c o mplic a tions oth e r than gr o wth restricti o n. (WILLIAM S ) Umbilical artery Do p pler be c om e s ab n orm a l wh e n at lea s t 3 % of the fetal villous stru c ture is a b n o rmal. ( J A M ES)

24. In ex t re m e cases of growth rest r iction, en d - dia s to l ic f l ow may become absent or even reversed (ARE D F). ARE D F occurs when 60 - 70% of t h e fe t al vi l lo u s s t ructu r e is abnor m al. About ½ of t h e cases of ARE D F are ass o cia t ed wi t h aneuplo i dy or a ma j or anoma l y (WIL L I A MS) Fetu s es of preecla m p tic women w ho had A R E D F were m ore l i kely to have hypog l yce m ia & polycy t hem i a . (WIL L I A MS)

25. ABNORMAL Umbilica l ARTERY WAVEFORM

26. Peri n atal m o r tality rate in AE D F - 9- 4 1 % (I A N DON A LD’ S )

27. Re v ers a l of the End Diast o lic Flow Peri n atal m o r tality rate of R E D F- 33- 7 3 % (I A N DO N ALD ’ S)

28. Ab n or m al U m bil i c a l ar t e r y f l ow p a t t e rn indic a te an i ncr e a s ed ri s k of h y p o xe m ia & a c ide m ia pr o p o rt i o n a t e to s e veri t y o f D o p p l e r ab n orm a l i t y . (JAMES) U m bil i c a l a r t e ry Do p pler c a n a l so be used to di s t i n g uish b / w the hi g h ri s k s m a l l fetus that is truly gr o wth re s tr i c t ed that needs inc. m o n i t oring & the l ow ri s k s m a l l fetus. ( I AN D O N A L D’ S ) W h en Umbi l i c al ar t ery D o p p l e r are incorp o ra t ed into m anage m ent a l g o ri t hm of growth re s tr i c t ed fe t us, perinat a l death is reduced as m uch as 2 9 %. (ST U DD) In su mm a r y UA Do p pler in s uspec t ed IUGR pregnanci e s i m pr o ves perinat a l o u t c ome & sho u ld be used to m o n i t or these fe t uses

29. MIDDLE CEREBRAL ARTE R Y(MCA) DOPPLER It was used for ass e ssm e nt o f - Fetal An e mia Gr o wth restricti o n FE T AL ANEMI A : (In R h isoimm u nis a ti o n ) W ith incr e asing an e mia  car d iac out p ut incr e ases & blo o d vis c osity d e cr e as e s  inc r e a se flow to brain  Elevated pe a k systolic velo c ity . WILLIAMS 23rd EDITION

30. Normal MC A WAVEFORM

31. MCA DOPPLER IN FETAL ANEMIA

32. GROWTH RE S TRICTIO N : It is in v olv e d in sev e rely gr o wth restrict e d fet u s after inv o lve m e n t of Um b ilical arte r y . It is the pro g res s ion of the Do p pler fin d ing & is d u e to the ad a ptive c o mp e ns a tory me c h a nism in the fetus a g ain s t inc r e a sing h y p o xia (Brain sp a ring e f fe c t)

33. In cre a si n g h y p o x i a Inc. blood flow to V i t al O r gans(Brain, Heart& Adren a ls) BR A IN S P A R I N G EF F ECT Or CEPHALI S A TION Dec. blood flow to Abdo m in a l O r gans(Liv e r & Kidne y s) OL I GOHY D R A MI N OS M CA D O PP LER- I n c. Diastolic F l ow De c . R I / P I/ S D r atio & abn M C A - P SV

34. MCA WAVEFORM IN IUGR I N C R EA S ED FL O W D U R I NG D I A S T OLE

35. CEREBR O-PLACEN T AL R A TIO(CPR) : MCA Pulsatility In d ex Umbilical A. Pulsati l ity In d ex It is m o re se n sitive ind e x for d e tecting p o or peri n atal out c ome than UA or MCA Do p pler alo n e, b u t d u e to non sta n d a rdi z ed tec h niq u e of c a lcul a ting CPR limit its clinic a l utilit y . (STUD D )

36. Abnormal MCA ref l e cts inc risk of ad v erse p e ri n atal outcom e ( P TL, In t rapart u m a c ide m ia & inc NICU adm i ss i on) Not super i or t o Umbi l ical ar t ery Doppler High negat i ve predic t ive value for adverse outco m e Normal U A & M CA Dopp l e r indi ce s & normal AFI i n grow t h rest r ic t ed fetus < 32 wks have n e gative predic t ive value of 97% for adverse outco m e

37. SUMMA R Y OF MCA: De s pite the ass o ciation of abn . MCA & ad v erse p e rin a tal o u tco m e, the r e are no sp e cific inter v e n ti o ns to impro v e o u tco m e b a sed on abn . fin d ing s . Ho w e v er abn . v a lues sh o uld pr o mpt mo r e fre q u e nt fetal sur v illence

38. Ve n ous Doppler studies Refle c ts fetal c a rdi a c fu n ction Most co m mo n ly us e d V en o us Do p pler indic e s : Du c tus V e n os u s Inf e rior v e na c a va He p atic vein Um b ilical v e in(I n tra a b d o min a l p o rtion)

39. Ductus ve n osus doppler PERIN A T AL MO R T ALITY IN ABSENT OR REVER S E F L OW OF DV IS 63 -1 0% (I A N D O NA L D ’S)

40. HYPOXIA INC BLOOD S H U N TING THRO U GH DV B/W U M BILICAL VEIN & IV C INC. P U LS A TI L ITY IN D EX F OR VEINS (PI V ) REVERSED a W A VE IN DV P U LS A TION P U LS A TIONS IN THE U M BILICAL VEIN REVERSAL OF FLOW IN IVC D U RING A TRIAL CO N TRACTION

41. ABNOR M AL WAVEFOR M IN UMBILICAL VEIN UMB I LICA L VEIN

42. Importa n t point s o n v enous Doppler Esp e cially us e ful in early o n set IUGR Re a son: In T erm /ne a r term fetus e s the r e is sh o rter inter v al & deliv e ry is oft e n indi c ated W ith a d v a n c ing GA c a rdi a c a c tivity b e c o mes mo r e e f ficie n t  slow Steady d e cline in Dop p ler indi c es When DV & Umbilical vein Do p ple r - Sensitivity inc to 7 -8 %.

43. Other investigations Amniocen t es i s Karyotyping Colour doppler T O R CH te s t Antiphospho l ip i d ant i body Thro m boph i l l ia scr e en Thyroid funct i on te s t Detai l ed level II ul t rasound Bioph y s i cal Pro f i l e(BPP) Cardio t ocography

44. Presumptive diagnosis of IUGR Symphysis Fundal Height not increasing at a n or m al r ate Fetus with s m all AC Flatte nin g of gr o wth cu r ve on two con s e c u t iv e occ a si o n 14 days apart B e y o nd 24 wks., an e levat e d u m bi l ic a l artery Dop pler index After 34 wks umbilical a rtery Dop pler in d ex m ay be n or m al & a de c . CPR or M C A Do p p l er in d ex m ay be the o n ly su p p orti n g evidence of p l a c enta l - based IUGR

45. Thank you….