USG AND DOPPLER IN DIAGNOSIS AND MANAGEMENT OF IUGR

This ppt include maximum information regarding IUGR.
Mainly diagnosis and management.

1. USG & DOPPLER IN DIAGNOSIS & MANAGEMENT OF IUGR Dr. Shivshankar Lasune (MS Obstetrics and Gynaecology)

2. SGA(small for gestational age) Def: a fetus that has not attained or achieved a particular biometric parameter threshold for given gestational age. Most universally accepted parameter is EFW 10 th centile. Other parameters AC, HC, BPD - 5 th centile.

3. Appropriate sensitivity for fetal risks Lower the centile - greater the risk of IUD Perinatal mortality & morbidity increases when birth weight is less than 3 rd & 5 th centile for gestational age. Why 10 th centile ? AGA FGR SGA LGA SGA 70% LGP 30% FGR

4. MATERNAL RISK FACTORS PIH Hypertension Diabetic vasculopathy APLA Renal disease Heart disease Asthma Hbpathy PKU Severe malnutrion Smoking Substance abuse

5. FETAL FACTORS Multiple gestation Infection Malformation Syndromes

6. PLACENTAL FACTORS Confined placental mosaicism Placenta previa Abruption Infarction Circumvallate placenta Morbid adherence Velamentous insertion

7. NORMAL GROWTH

8. PHASES OF GROWTH WILLIAMS OBSTETRICS -24rd EDITION

9. GENETIC POTENTIAL Derived from both parents Mediated through factors like insulin like growth factor SUBSTRATE SUPPLY Derived from placenta Depend upon Uterine & Placental vascularity GROWTH DEPENDS UPON:

10. SUBSTRATE TRANSPORT

11. Small for gestational age Low growth profile Constitutionally small Serial monitoring Curve to nomograms or parallel Anatomy normal BPP/AF normal Doppler normal No treatment Smallness is not equal to sickness Fetal growth restriction (fetal cause) Syndrome/ anomoly / aneuploidy Serial monitoring Curve drops off Anatomy normal/abnormal AF normal/ abnormal Doppler normal/ abnormal Karyotype, inf., markers of aneuploidy.

12. Small for GA Fetal growth restriction – classical placental cause Failure to attain genetic potential Serial monitoring Curves drops off (cuts across percentile) Body disproportion Anatomy normal BPP Normal / Abnormal Amniotic fluid Normal/ Abnormal Doppler Normal // Abnormal Surveillance for fetal growth and well being Optimisation of the time of delivery Decreases perinatal morbidity and mortality

13. SGA = EFW < 10 th percentile Constitutionally small 70% EFW 4 to 10 th percentile UAD –N CPR – N Ut AD – N Placental histology – normal Maternal biochemical parameter – Normal Good outcome Intra uterine growth restriction 30% EFW < 3 rd percentile or UAD – Abnormal or CPR - < 5 th percentile or Ut AD - Abnormal Placental morphology – Abnormal. Maternal biochemical parameter -Abnormal Poorer outcome

14. Distribution of cases when IUGR = abnormal UA Doppler

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

16. Prognostic criteria of “poor outcome”-SGA! CS for distress and/or neonatal acidosis

17. FGR classification Early vs Late Symmetric vs Asymmetric Early onset FGR – Diagnosed before 34 weeks of GA Cellular hyperplasia is stunted Proportionally small fetus (EFW < 10 th pct) Late onset FGR – Diagnosed after 34 weeks Cellular hypertrophy stunted Disproportionally small fetus (EFW< 10 th pct) HC/AC and FL/AC ratios ( assymetric ) Substrate inadequacy Associated with maternal disease

18. Importance of early vs late Cause – Severity – Counselling - Management

19. Summary of the main difference between early and late onset forms of FGR Early onset FGR 1- 2% Problem : management Placental disease : severe ( UA Doppler abnormal, high association with preeclampsia) Hypoxia ++ :systemic cardiovascular adaptation Immature fetus = higher tolerance to hypoxia = natural history High mortality & morbidity Lower prevalence 20 – 30% of FGR Late onset FGR 3 – 5% Problem : diagnosis Placental disease : mild ( UA Doppler normal, low association with preeclampsia) Hypoxia +/- : central cardiovascular adaptation Mature fetus = lower tolerance to hypoxia = no or very short natural history Lower mortality but common cause of late stillbirth, affects large fraction of pregnancy 70 – 80 % of FGR .

20. EARLY ONSET FGR

21. LATE ONSET FGR

22. Nomogram concept Portrays relation between two variables In the context of fetal growth (Fetal size – cms or kg vs Time – weeks ) Biological diversity / variability Continuous foetal growth Graph or chart forms Gives mean & confidence limits of a parameter for a given gestational age Standard deviation / percentile

23. Biological variability of foetal size Ethical Altitude Social - Economical Racial Birth order The variability of range in size for a given gestation increases with advancing gestational age.

24. Percentile HC 95 1 2 3 4 5 6 7 8 9 10 .............................................................50..................................................................................95...................

25. Percentiles Arrange 100 items in order of magnitude The 50 th item has 49 items below & 50 above – 50 th percentile The 95 th item has 94 items below & 5 above – 95 th percentile The 5 th item has 4 items below & 95 above – 5 th percentile +2SD = 97.72nd percentile -2SD = 2.28 th percentile

26. SIZE TIME A lot of dolls rolled out from a factory

27. Foetal population is heterogeneous Much like the adult population size TIME Ethnic, Racial, Social & Economic influences y x

28. TIME SIZE SIZE TIME Difference between the two graphs x x y y

29. Y Y TIME SIZE SIZE TIME DATING GROWTH X – axis known parameter Y – axis derived information x x y y

30. Foetal size Gestational Age cms weeks Dating Growth

31. US determination of GA – Dating scan Good in the 1 st trimister & 1 st half of 2 nd trimister. First trimister - CRL up to 13wks + 6 days Second trimister – BPD, HC, AC and FL Dating is poor in the 3 rd trimister Reassignment is done if there is more than one week difference from menstrual age. If not the Menstrual age is validated. Once reassigned the GA is not changed during the rest of the gestation.

32. RELIABILITY OF US DATING +/- 8% of actual gestational age 10weeks +/- 6 days 24 weeks +/- 14 days 34 weeks +/- 20 days

33. Essence Of Diagnosis Of Fetal Growth Growth Normal / Abnormal Date – Determination of Gestational age Plot – Determination of growth Date – only once (earliest) Plot – more than once (growth) No diagnosis of fetal growth or disorders without plotting growth curve.

34. Case study LMP – 14- 3- 16 ; Dating scan – 11- 5- 16 ; MA = 9 weeks. CRL = 2.7 cms = 9 weeks Hence US GA correlates with MA 2 nd Scan 2- 8- 16 GA = 8-9 weeks + interval = 9 wks + 11 wks = 20 wks. The biometry is then done and the results are : Parameter cms BPD 4.8 HC 17.3 AC 15.2 FL 3.0

35. CASE STUDY The dating scan could be from another centre in your town / city / country 2 nd scan – 2 – 8- 16 GA = 8-9 weeks + interval = 9 wks + 11 wks = 20 wks. The biometry is then done and the results are : Parameter cms BPD 4.8 HC 17.3 AC 15.2 FL 3.0

36. Case study Hence 2 nd scan parameters fall within the confidence limits for 20weeks and therefore the interval growth is normal. 3 rd scan 12 – 11 – 2016 GA = 9wks + interval = 9 wks + 26 weeks = 35 weeks The biometry is Parameters cms BPD 7.6 HC 29.3 AC 25.5 FL 6.0

37. DOPPLER

38. Doppler effect: Change in the apparent frequency due to relative motion between the source & the observer. (Doppler probe & RBCs) When the sound wave strikes a moving target, the frequency of sound waves reflected back is proportionate to the velocity & direction of moving object. Used to determine the volume & rate of blood flow through vessels.

39. Types: CONTINUOUS WAVE DOPPLER: Two crystals are used, one transmits & other receives wave Used in M-mode echocardiography PULSE WAVE DOPPLER: Only one crystal that Transmits- wait -Receives- wait -Transmits Allows precise targeting & visualization of the vessel of interest Have software that displays blood flow- Towards transducer as RED Away from transducer as BLUE

40. Angle of Insonation : Between Doppler beam & direction of flow Higher the angle lesser the frequency & more the error.

41. Frequency change relative to angle of insonation

42. To minimize error we use RATIOS, to cancel off the cos ϴ Arterial Doppler indices S / D Ratio : Peak systolic flow(S) End diastolic flow(D)

43. PULSATILITY INDEX : S-D ----------- Mean RESISTANCE INDEX : S-D ---------- S Venous Doppler indices:

44. Quantitative analysis Doppler indices

45. MATERNAL SIDE Uterine artery PLACENTAL SIDE Umbilical artery FETAL SIDE Arterial: MCA, Aortic Isthmus Venous: Ductus venosus, Hepatic vein, Umbilical vein Fetal echocardiography Doppler vessels to be studied

46. PLACENTAL RESISTANCE CARDIC FAILURE U MBILICAL. V DUCTUS VENOSUS DESCENDING AORTA

47. Uterine artery Doppler Its main use is in screening. Early diastolic notch in the uterine artery @ 12-14 wks . suggest delayed trophoblastic invasion . Persistence of B/L notch beyond 24 wks confirms & indicates an increased risk of Pre-eclampsia, Placental abruption & Early onset IUGR. Increase impedence of flow in Uterine artery @ 16-20 wks was predictive of superimposed pre-eclampsia developing in women with chronic hypertension.

48. Utero placental circulation Conversion of spiral artery into utero placental vessel Brosens et al

49. NORMAL ABNORMAL

50. Uterine artery Doppler: As gestation increases diastolic flow velocities High diastolic flow velocities

51. UMBILICAL ARTERY UA Doppler is the only measure that provides both diagnostic and prognostic information for the management of FGR. On the one hand, increased UA Doppler PI has a great clinical value for the identification of FGR , alone or combined in the CPR ratio. On the other hand, the progression of UA Doppler patterns to absent or reverse end-diastolic flow correlates with the risks of injury or death. When Umbilical artery Doppler are incorporated into management algorithm of growth restricted fetus, perinatal death is reduced as much as 29%. Umbilical artery Doppler becomes abnormal when at least 30% of the fetal villous structure is abnormal. In extreme cases of growth restriction, end-diastolic flow may become absent or even reversed (AREDF).

52. AREDF occurs when 60-70% of the fetal villous structure is abnormal. About ½ of the cases of AREDF are associated with aneuploidy or a major anomaly Absent or reversed end-diastolic velocities, the end of the spectrum of the abnormalities of the UA Doppler, have been reported to be present on average 1 week before the acute deterioration . There is an association between reversed end-diastolic flow in the UA and adverse perinatal outcome (with a sensitivity and specificity of about 60%), which seems to be independent of prematurity. After 30 weeks the risk of stillbirth of a fetus with isolated reversed end-diastolic velocities in the UA Doppler overcomes the risks of premaurity.

53. UMBILICAL ARTERY DOPPLER The amount of flow during diastole increases as gestation advances Thus the S / D ratio and PI decreases.

54. ABNORMAL Umbilical ARTERY WAVEFORM Resistance index, S / D ratio and PI is increasing

55. ABNORMAL Umbilical ARTERY WAVEFORM Perinatal mortality rate in AEDF- 9-41% .

56. ABNORMAL Umbilical ARTERY WAVEFORM Reversal of the End Diastolic Flow. Perinatal mortality rate of REDF- 33-73% .

57. UMBILICAL ARTERY DOPPLER Umbilical arteries NORMAL HIGH RESISTANCE ABSENT REVERSAL

58. MIDDLE CEREBRAL ARTERY DOPPLER Middle cerebral artery pulsatility index < 5 th percentile is considered early stage change of IUGR . The nadir of MCA PI is reached 14 days or more before fetal compromise. Normalisation of MCA PI The reversal of adaptation in growth restricted fetus is considered a poor prognostic sign. Due to cerebral edema. MCA informs about the existence of brain vasodilatation, a surrogate marker of hypoxia . Abnormal MCA PI had a six fold risk of emergency caesarean section for fetal distress when compared with SGA fetuses with normal MCA PI . Abnormal MCA PI is associated with poor perinatal outcome and @ 2 years neurological outcome.

59. Umbilical artery involved Increasing hypoxia Inc. blood flow to Vital Organs(Brain, Heart& Adrenals) BRAIN SPARING EFFECT Or CEPHALISATION Dec. blood flow to Abdominal Organs(Liver & Kidneys) OLIGOHYDRAMINOS MCA DOPPLER- Inc. Diastolic Flow Dec. RI/PI/SD ratio & abn MCA-PSV

60. REFLEX REDISTRIBUTION OF FETAL CARDIAC OUTPUT KIDNEYS (OLIGURIA) (OLIGOAMNIOS) LUNGS (RDS) GUT (NEC) LIVER/MUSCLE (IUGR) BODY FAT/ GLYCOGEN STORES INCREASED FLOW DECREASED FLOW BRAIN HEART ADRENAL

61. Normal MCA WAVEFORM

62. MCA WAVEFORM IN IUGR INCREASED FLOW DURING DIASTOLE

63. CEREBRO-PLACENTAL RATIO(CPR): MCA Pulsatility Index Umbilical A. Pulsatility Index The CPR is essentially a diagnostic index . It is more sensitive index for detecting poor perinatal outcome than UA or MCA Doppler alone, the CPR is already decreased when its individual components suffer mild changes but are still within normal ranges. Abnormal CPR predicts neurobehavioral problems at 18 months of age.

64. AORTIC ISTHMUS DOPPLER This vessel reflects the balance between the impedance of the brain and systemic vascular systems. Strong association with both adverse perinatal and neurological outcome. AoI precedes Ductus Venosus abnormalities by 1 week.

65. DUCTUS VENOSUS It is strongest single Doppler parameter to predict the short-term risk of fetal death in early-onset FGR. DV flow waveforms become abnormal only in advanced stages of fetal compromise. There is a good correlation of abnormal DV waveform with late- stage acidemia at cordocentesis. Absent or reversed velocities during atrial contraction are associated with perinatal mortality independently of the gestational age at delivery , with a risk ranging from 40 to 100% in early-onset FGR . In about 50% of cases, abnormal DV precedes the loss of short-term variability (STV) in computerized cardiotocography (cCTG), and in about 90% of cases it is abnormal 48–72 h before the biophysical profile (BPP).

66. Protocol IUGR First step: UtA + CPR + EFW = SGA or IUGR

67. STEROID PROPHYLAXIS RCOG Single course of antenatal corticosteroids to women between 24+0 to 34+6 weeks of gestation who are at risk of preterm delivery. Antenatal corticosteroids can be considered for women between 23+0 to 23+6 weeks gestation who are at risk of preterm delivery, decision should made at senior level. IUGR Single course of antenatal corticosteroid should receive between 24+0 to 35+6 weeks of gestation who are at risk of preterm delivery. Antenatal corticosteroids should be given to all women for whom elective LSCS planned before 39 weeks .

68. continue Single rescue course may be considered where initial course was given at less than 26+0 weeks . In multifetal gestation single course of antenatal corticosteroids should be given between 24+0 to 34+6 weeks gestation at risk of preterm delivery. Regularly scheduled repeat courses or serial courses of antenatal corticosteroids are not recommended .

69. ACOG Single course of antenatal corticosteroids should given to women between 24+0 to 33+6 weeks of gestation at risk of preterm delivery. ( PPROM, MULTIPLE GESTATION, FGR ) Also consider for 23 0/7 weeks if risk of preterm delivery within 7 days , based on family decision regarding resuscitation. Single course of corticosteroid should given between 34 0/7 to 36 6/7weeks at risk of preterm delivery within 7 days , who have not received a previous course of corticosteroid. Single rescue course of antenatal corticosteroid should be considered in women less than 34 0/7 weeks of gestation at risk of preterm delivery within 7 days & prior course given more than 14days .

70. continue Rescue course should be provided as early as 7 days from the prior dose, if clinically indicated. Regularly scheduled repeat courses or serial courses of antenatal corticosteroids are not recommended .

71. DOSAGE Inj. Betamethasone 12mg i.m 2 doses 24 hrs apart. Inj . Dexamethasone 6mg i.m 4 doses 12 hrs apart. Betamethasone most preferred to Dexamethasone Most effective 24 hrs after and up to 7 days after administration second dose of antenatal corticosteroids.

72. ADVERSE EFFECT OF MULTIPLE DOSES OF STEROIDS Fetal growth restriction Reduced birth weight Reduced HC Delayed myelination of CNS Altered blood pressure soon after birth Increased insulin response to glucose challenge in early childhood. Behavioural disorders at 3 years of age. Placental infarction Adrenal gland insufficiency

73. Complications of iugr Perinatal morbidity & mortality of IUGR infants is 3-20 times greater than normal infants. ( IanDonalds ) Risk is increased 3 times at 26 weeks compared with only a 1.13-fold increased risk at 40 weeks. ( Williams 24 rd edition )

74. Complications (Cont…) Antenatal Period: Oligohydraminos Fetal Distress IUD During labour: Meconium aspiration Fetal distress Acidosis Still birth

75. Neonatal period: Hypoxic Ischemic Encephalopathy Persistent Fetal circulation Difficulty in temperature regulation Hypoglycemia Polycythemia Necrotising Enterocolitis

76. Childhood: Infectious Diseases Cerebral Palsy(4-6 times higher) Subtle impairment in cognitive improvement Educational underachievement

77. Long term: Increase risk of  Coronary Heart Disease Hypertension Type II Diabetes Mellitus Dyslipidaemia Stroke

78. BARKERS HYPOTHESIS David J P Barker British epidemiologist

79. Management algorithm depends heavily on  Gestational age  Doppler changes Difficult extrauterine environment Hostile intrauterine environment PREMATURITY IUGR

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