Speaker honorarium - Lumara Health No conflicts with respect to - - PowerPoint PPT Presentation

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Speaker honorarium - Lumara Health No conflicts with respect to - - PowerPoint PPT Presentation

Oct 19, 2023 155 likes •280 views

Speaker honorarium - Lumara Health No conflicts with respect to this lecture William M. Gilbert, MD Regional Medical Director, Sutter Health & Clinical Professor Department of OB/GYN University of California, Davis One SD A. 47%

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SLIDE 1

William M. Gilbert, MD Regional Medical Director, Sutter Health & Clinical Professor Department of OB/GYN University of California, Davis Speaker honorarium - Lumara Health No conflicts with respect to this lecture A.

One SD

B.

Two SD

C.

Three SD

  • D. None of the above

17% 16% 21% 47%

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SLIDE 2

A.

AC < 10% centile

B.

AC < 5th% centile

C.

AC < 3rd centile

  • D. None of the above

11% 43% 27% 19%

Definitions

  • Birth weight < 2500 gm
  • EFW < 10th centile
  • Abdominal circumference < 10th centile
  • EFW < 10th centile AND abnormal Dopplers
  • AC < 10th centile AND abnormal Dopplers

SGA relates to newborns < 10th centile

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SLIDE 3

40% of total birth weight due to genetic

factors

  • Maternal primary influence

IUGR in mother increased in offspring

60% environmental factors

  • Nutrition
  • Smoking
  • Placental factors

Maternal medical conditions

  • Pregestational diabetes
  • Renal insufficiency
  • Autoimmune disease
  • Cyanotic cardiac disease
  • Pregnancy related hypertension

Chronic HTN, Gest HTN, PE

  • Antiphospholipid antibody syndrome

Substance use and abuse Multiple gestations Teratogen exposure

  • Chemo agents, valproic acid, antithrombotic drugs

Infectious disease

  • TORCH, CMV, malaria, syphilis, Zika

Genetic and structural disorders

  • T-13, T-18, CHD or gastroschisis

Placental disorders

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SLIDE 4

Before birth

  • Increase in Stillbirth, C/S for fetal distress,

meconium staining of amniotic fluid

Afterbirth - Birth weight < 10th centile

  • PVL, CP
  • Later life:

Hypertension Heart disease DM

Indirect measure of blood flow Not a good screening tool alone Is effective with IUGR fetuses Becomes abnormal before FHT variability Fd = 2F*V*COS theta

1540 cm/sec

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SLIDE 5

Most useful with diagnosing fetal anemia

  • Used with rH isoimmunization and anti Kell
  • Did away with:

Amniocentesis for Delta-OD450 Use of the Lilly curve

With fetal hypoxia

  • Decreased resistance allowing an increase in blood

flow to the brain

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SLIDE 6

Ireland -1200 consecutive pregnancies EFW<

10th centile

1/2010 through 6/2012 Examined EFW or AC <10th, <5th, <3rd centile

  • Every two weeks

Abnormal Doppler, oligohydramnios Adverse Outcome index

  • Death, IVH, RDS, PVL, HIE, BPD, sepsis

Average maternal age - 30 years old 83% white European decent Mean GA at enrollment - 30.1 weeks Mean Delivery GA - 37.8 weeks NICU admission - 28% Adverse outcome 5.2% Mortality 0.7% 72% had a normal outcome

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EFW < 10th centile alone:

  • No increase in M&M

Real increase in Morbidity and Mortality

  • Abnormal UA Doppler in all EFW < 10th centile
  • Oligohydramnios important only with EFW < 3rd

centile

  • Only weight related basis was EFW < 3rd centile

1/2008 through 7/2012 EFW < 10th centile 789 with IUGR (7%) Excluded: multiples, anomalies, absent or

reversed Doppler EDVs

Leaving 512

  • 394 with normal UA Doppler
  • 118 with UA Doppler > 95th centile
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SLIDE 8

Protocol to get Abnl UA Doppler to 37 weeks

  • 36 4/7 weeks
  • Birth weight < 10th centile - 84.7%
  • Mean 2.178 kg

Normal UA Doppler to 39 weeks

  • 37 6/7 weeks
  • Birth Weight < 10th centile - 66.2%
  • Mean 2.532 kg

After controlling for demographic and GA at

delivery etc

No difference in:

  • NICU admissions
  • Composite neonatal morbidity
  • Perinatal deaths

Conclude: In cases of IUGR with:

  • Abnormal UA Doppler, delivery at 37 weeks
  • Equals 39 weeks with normal UA Dopplers

Ratio of MCA Doppler PI to UA PI Retrospective cohort study IUGR pregnancies Adverse outcomes, IVH, death, NRFHT, pH<

7.0, Apgar at 5 < 7, PVL, RDS

183 identified with 70 at least 1 adverse

event

Compared CPR < 1.08 and CPR < 5th centile

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SLIDE 9
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SLIDE 10

CPR predictive of poor outcome in:

  • AGA fetuses
  • SGA fetuses

May be a screening tool for ALL pregnancies

in the third trimester

Better than the biophysical profile Better than UA and MCA Dopplers alone Definition of IUGR is not well defined

  • EFW < 10th centile most commonly used
  • EFW < 3rd centile more predictive of poor outcome
  • With Abnormal UA Doppler, real increased risk of

poor outcome

  • Oligohydramnios - Less important but still

recommended

CPR appears to be better for identifying

adverse outcome but further confirmatory studies needed

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SLIDE 11

Day to Day management

  • Suspect IUGR? Ultrasound including UA Doppler
  • EFW < 10th centile with UA Doppler normal?

Deliver at 39 weeks, Repeat US in 2-3 weeks NSTs OK

  • EFW < 10th centile and UA Doppler Abnormal?

Deliver at 37 weeks or earlier PRN NSTs definitely

Absent or Reversed End Diastolic velocities?

  • Hospitalize and or deliver