2nd International

Conference on Fetal Growth

September

19-21st,

Proposed origins of damage

2013
abnormal
Umbilical

Management of early onset

fetal growth restriction

Brain sparing

abnormal
venous
Doppler

Ahmet A. Baschat, MD

Acidemia

abnormal
cCTG

Delivery !

neurologic

abnormal
biophysical

Professor, Director of Maternal-Fetal

Medicine and Section of Fetal Therapy
University of Maryland School of Medicine

Hypoxemia

Damage

Stillbirth
James 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.

Determinants of outcome

If this were true

FGR fetuses should be normal before deterioration

NEURODEVELOPMENT

Deterioration should be associated with worse

neurodevelopmental outcome
Early intervention should make a difference

ACIDEMIA

MORBIDITY

STILLBIRTH

MORTALITY

FETAL RISK

NEONATAL RISK

Baschat 2012

Am J Obstet Gynecol 2011

100

+ 2% / Day in utero

+ 1% / Day in utero

90
80
70
60

consideration: Gestational age

Survival

Intact

50
Percent

1st

40
30
20

BW < 600
GA <27.0
(r2=0.48)

10
0
24

25

26

DV Doppler only has an

independent impact on Survival
from 28 weeks on
27

28
Gestational week

29

30

31

32

Baschat et al, Obstet Gynecol., 2007

1
1

Oxford Vermont Network

547 singleton / Twins - 24-36 GA

Comparing Steroid benefits in preterm IUGR & AGA

Unsure about delivery timing

Immediate
delivery

BJOG 2003
C-section
FDIU
neonatal Death

Deliver when no
longer in doubt

+4.9 days
(*6.9 > 31 SSW)

91%
2
27

<0.05
<0.05
0.06

76%
9
18

Perinatal Mortality

29

n.s.

27

Prematurity-related

17

<0.05

19 759 VLBW infants IUGR vs. AGA

RDS
NEC
IVH
Neonatal death

1.19
1.27
1.13
2.77

(1.03
(1.09
(0.99
(2.31

1.36)
1.57)
1.29)
3.33)

IUGR & AGA = equal benefit from steroids

<30 weeks

(Am J Obstet Gynecol 2000)

Maternal indications, e.g. pre-eclampsia

Abnormal biophysical profile score

Delay to
gain
viability

Delay to gain
survival

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

24

+2% survival / D
if in doubt wait
Excellent
monitoring
necessary

26

28

Delay to improve
morbidity

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

30

Delay for
steroids

2nd consideration: Fetal deterioration

Steroids
decrease RDS,
NEC &
mortality

34

38

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

Biophysical parameters

When should a small fetus be

delivered?

pH

Hypoxemia
Acidemia
Organ damage (brain damage)
Stillbirth

Neonatal risks
Poor transition
Prematurity & complications
Organ damage (brain damage)
Neonatal death

Doppler parameters
Abnormal
UA

Absent tone
& movement

Brain
sparing

Abnormal
DV

-2

When the baby is better off outside the uterus

Fetal risks

NonOligohydramnios
reactive
(<2 cm)
CTG Absent
STV
<3.5
breathing

-4

-6

pH < 7.20

pH < 7.10

-8

abnormal cCTG and DV

-10
comparable
pH range

Biophysical parameters
have closer relation to pH

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.

2
2

Combination of tests improves prediction

N = 1024

100

Percent

90

Sensitivity

100

91%

90
78%

80

Percent

Venous Doppler provides best prediction, cCTG

best if combined with venous Doppler or if
substituted for the traditional NST in the BPS

Abnormal venous Doppler

Abnormal biophysical parameters
Both abnormal
Sensitivity & Specificity = 179

70
60
50

false positive rate

80
70
60
50

40

40

30

30

20

20

23%

17%

10

10

0
Acidemia

Acidemia

Stillbirth

Stillbirth

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

Ultrasound Obstet Gynecol 2007; 30: 750-56

Early onset
compensated
4 6 weeks

hypoxemia

34 weeks

3rd consideration: Monitoring interval

32 weeks

acidemia

28 weeks

Abnl BPP

Deliver at any GA

Stillbirth

What do you need to do when

you are not yet planning to
deliver?

See the patient again in an appropriate

Early onset
compensated

weekly

interval

hypoxemia
2-3 x weekly

Monitoring risks

Hypoxemia

Acidemia

Stillbirth

Hypoxemia
Acidemia
Organ damage
Stillbirth
If you don
t see the patient
frequently enough

daily

acidemia
Abnl BPP

Delivery
(+/- Steroids)

Deliver at any GA

Stillbirth

3
3

Gradually decreasing delivery threshold

High delivery threshold

STV < 3.5 & decelerations

STV <
3.5
DV - RAV

DV RAV & pulsatile UV

Shorten monitoring interval for
UA-AREDV, DV-RAV, Oligo

STV < 4 msec

DV > 3SD

STV<5 ms ?

UA-REDV

UA-AEDV

MCA

Shorten monitoring interval for

UA-AREDV, DV-PI, Oligo.

Severity of placental dysfunction determines 2 rates of progression

4 Weeks
UA

MCA

UA

DV

UV

MCA

BPP
DV

UV

BPP

6 Weeks

Deliver for maternal indications or biophysical profile < 6

Administer steroids for anticipated delivery
+2 % Survival / day in utero

Periviability
>50% Mortality

24

26

< 50%
Intact
survival

Increased
prospective
stillbirth
rate

+1 % Survival / day in utero

Worse outcome with fetal

decompensation

28

30

32

34

38

4
4