Download - Color doppler in FGR making sence of waves
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PROF.NARENDRA MALHOTRAM.D., F.I.C.O.G., F.I.C.M.C.H, F.R.C.O.G.,F.I.C.S.,F.M.A.S.,F.I.A.P.
• Prof. Dubrovnick International University
• V.P. WAPM(world association of prenatal medicinne)
• President ISAR
• Presiddent Elect ISPAT
• Sec Gen SAFOG
• Member FIGO guidelines committee
• President FOGSI (2008-2009)
• Dean I.C.M.U. (2008)
• Director Ian Donald School of Ultrasound
• National Tech. Advisor for FOGSI-G.O.I.—Mc Arthur Foundation EOC Course
• Managing Director GLOBAL RAINBOW HEALTH CARE
• Director ART-RAINBOW –IVF
• Practicing Obstetrician Gynecologist at Agra. Special Interest in High Risk Obs., Ultrasound, Laparoscopy
and Infertility, ART & Genetics
• Member and Fellow of many Indian and international organisations
• Awarded best paper and best poster at FOGSI : 5 times, Ethicon fellowship, AOFOG young gyn. award,
Corion award, Man of the year award, Best Citizens of India award
• Over 50 published and 200 presented papers
• Over 100 guest lectures given in India & Abroad and 24 ORATIONS
• Organised many workshops, training programmes, travel seminars and conferences
• Editor 18 books, many chapters, on editorial board of many journals
• Editor of series of STEP by STEP books
• Revising editor for Jeatcoate’s Textbook of Gynaecology 7th and 8th edition (2015)
• Very active Sports man, Rotarian and Social worker
MALHOTRA NURSING & MATERNITY HOME PVT. LTD.
GLOBAL RAINBOW HEALTH CARE,AGRA
84, M.G. Road, Agra-282 010Phone : (O) 0562-2260275/2260276/2260277, (R) 0562-2260279, (M) 98370-33335; Fax : 0562-2265194
www.malhotrahospitals.com,www.rainbow hospitals.org
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Color doppler in FGR making sense of the waves
Narendra MalhotraJaideep Malhotra
Neharika Malhotra BoraRishabh Bora
Ashok Khurana,S Suresh,Kuldeep Singhwww.rainbowhospitals.org
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OBJECTIVES OF THIS TALK
• Describe Doppler technique in different blood vessels
• Discuss Doppler role in FGR fetuses
• Understand the value of Doppler in fetal anemia
• Present Doppler frontiers
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COLOR DOPPLER
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Principles of Color Doppler
Color flow mapping
Power Doppler
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THE DOPPLER EFFECT
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Principles of Color Doppler
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Quantitative analysis
Doppler indices
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3D DOPPLER
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UTERO-PLACENTAL CIRCULATION
• PLACENTAL CIRCULATION– progressive maturation of
the placenta and increase in the number of tertiary stem villi.
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Sadler TW Lagman’s Medical Embryology 1990
Umbilicalvessels Chorionic
vesselsChorionic
plate Amnion
Spiralartery
PlacentalseptumBasal
plateUteroplacental
veins
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FETAL CIRCULATIONARTERIAL VENOUSCARDIAC HEMODYNAMICS
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CLINICAL APPLICATIONS
• Common applications (FGR)
• Other applications (fetal anemia)
• New applications
• 3D Doppler
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DOPPLER IN IUGR
• To identify etiology of FGR
– Placental / non placental
• To identify hypoxia & fetal adaptation
• To plan timing of delivery?
• To identify fetuses at risk of perinatal complications
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DOPPLER IN FGR
• To identify vascular bed resistance
– Uterine artery
– Umbilical artery
• To identify fetal adaptation
– MCA
• To identify cardiac decompensation
– Ductus venosus
– Umbilical vein
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DOPPLER IN FGR
Doppler meta analysis has shown that the use of the UA
Doppler reduces the number of:• antenatal admissions: 44%
• inductions of labor: 29%
• C/S for NRFS: 52%
• perinatal mortality: 38%
Alfirevic Z, Neilson JP
ACOG 1995;172;1379-87
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A DOPPLER REPORT
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A REPORT
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FETAL HYPOXIA-ACIDOSIS
AORTIC BODY CHEMORECEPTOR STIMULATION
REFLEX REDISTRIBUTION OF FETAL CARDIAC OUTPUT
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REFLEX REDISTRIBUTION OF FETAL CARDIAC OUTPUT
INCREASED FLOWDECREASED FLOW
KIDNEYS (OLIGURIA)
(OLIGOAMNIOS)
LUNGS (RDS)
GUT (NEC)
LIVER/MUSCLE (IUGR)
BODY FAT/
GLYCOGEN STORES
BRAIN
ADRENALS
HEART
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UMBILICAL ARTERY
• Low impedance circulation
• S/D index (A/B index)
• Placental insertion has least impedance
• Intervene for absent or reversed EDF
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UMB ART SIGNIFICANCE
60% tertiary villous artery occlusion
>70% tertiary villous artery
occlusion
Trudinger, Br J Obstet Gynecol, 1985
Abuhamad, COG, 2003
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ABNORMAL UMB A WAVEFORMS
DECREASED EDF ABSENT EDF REVERSED EDF
Nicolaides, Placental and Fetal Doppler
Diploma in Fetal Medicine Series, 2000
Absent / Reversed End Diastolic flow is associated with severe IUGR, oligohydramnios,
increased risk of neonatal mortality and morbidity (cerebral hemorrhage, anemia and hypoglycemia).
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UA DOPPLER – REVERSED DIASTOLIC FLOW
This is an advanced stage of fetal compromise, associated with increased perinatal morbidity and mortality.
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MCA DOPPLER
• Most accessible cerebral vessel
• Carries 80% of cerebral flow
• Excellent reproducibility
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MIDDLE CEREBRAL ARTERY “FETAL ADAPTATION”
31 weeks, IUGR, PI=1.22 33 weeks, IUGR, PI=1.11
Decreasing trend in MCA PI suggests further blood flow redistribution to the brain.
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MCA DOPPLER
Normal
Abnormal – fetal hypoxia
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Alteredcerebroplacental ratio
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VENOUS CIRCULATION
Central:• ductus venosus, hepatic veins, IVC
– characteristic pulsations
Peripheral:• portal veins, umbilical vein
– no pulsations
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DUCTUS VENOSUS TURBULENCE (DV)
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• Reversal of A- wave flow in the DV - sensitivity of 53% for perinatal mortality.
• A-velocity below the 5th percentile in DV - 79%
sensitivity for fetal demise.
A cut-off value for DV PIV of 2–3 SD seems to be most appropriate for delivery. (C. M. BILARDO et al, UOG, 2004)
1st tri 2nd Tri 3rd tri
Normal DV wave forms
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VENOUS DOPPLER NORMAL FETUS
IVC Doppler
DV Doppler
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HYPOXIC FETUS
IVC Doppler
DV Doppler
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OBSTETRIC ULTRASOUNDPROTOCOLS OVER THE YEARS
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UTERINE ARTERY DOPPLER FOR PREDICTON OF IUGR
LR ut art dop IUGR
LR
Pre-eclampsia
LR
Perinatal death
LR
ABN 3.7 5 2.4
N 0.7 0.5 0.8
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UTERINE CIRCULATION
• Low impedance circulation in pregnancy
• S/D or RI – standard indices
• Low EDF & notching – abnormal findings
• Associated with elevated MS AFP & hCG
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UTERINE ARTERY
• Abnormal waveforms:
– FGR
– Pre-eclampsia
– FHR abnormalities
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NORMAL & ABNORMAL WAVEFORM IN ADVANCED PREG
Diastolic Notch(irrespective of the RI PI))
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FGR
• Challenge:
– Diagnose true IUGR
– Identify markers of morbidity
– Intervene in a timely fashion
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Evaluation of FGR
PIH/ HT/ DM/ Renal diseasePrevious FGR / Still birthAPA
Maternal
Fetal
USGto R/O structural abnormalitiesFetal echoInvasive fetal testingKaryotypingFetal infections
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TIMELINE FOR FETAL HYPOXIADOPPLER SUMMARY
• Abnormal fetal growth
• Abnormal arterial Doppler (UA, MCA)
~ 2 weeks
• Abnormal venous Doppler (IVC & ductus venosus)
~ 1-2 days??
• Abnormal NST / BPP score
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SEQUENTIAL CHANGES IN TESTS OFFETAL WELL BEING
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THE ACTION POINTS..
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Doppler
Incflow FetalMCAPI< 5th
Umbilical artery HRF PI> 95thplacental resistance
increasing hypoxia
acidosis Venoussystem-Ductusvenosus/umbveinearly/ late
Cerebroplacentalratio
MCA PI/ UA PI <1 or < 5thcentile
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Early vs Late onset FGR
Both have poorlongtermneurodevelopmental, cardiovascular, and metabolicparametresBoth are associated with placental disease but may be different types of diseaseGAcutoffis arbitrary and could be 32 weeks
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Early onset severe FGR
Mild late onset FGR
In severe maternal disease,
progression is unpredictable
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Aim of monitoring
TO INTERVENE IN TIME
Monitor growth Biometry
Detect hypoxia Doppler
PreventacidemiaDoppler/BPP/ CTG
Daily fetal movement count
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MONITORING – HOW OFTEN?
Frequency dictated by Severity of growth restriction Gestational age of the fetus
Biometry 2 – 3 weeks No value for biometry if interval is less than 2 weeks
Doppler 2 – 3 weeks if mild weekly / biweekly if severe dysfunction
AFI – weekly / bi weekly
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DOPPLER & FETAL ANEMIA
• Anemia:
– Increased cardiac output
– Decreased blood viscosity
– Increased blood velocity
• Peak systolic velocity of MCA
• Why MCA?
– Increased blood flow to brain in anemic fetus
– MCA lends itself to insonation angle close to zero
– Low inter- and intra-observer variability
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DOPPLER & FETAL ANEMIA
MCA PSV:
• Moderate to severe anemia:
– Sensitivity 100%
– FPR 12%
Mari C et al. NEJM 2000;342:9
• Parvo virus
– Sensitivity 94.1%
– Specificity 93.3%
ACOG 2002
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Aghajanian P et al. Fetal middle cerebral artery Doppler fluctuations after laser surgery for twin-twin transfusion syndrome.
J Perinatol. 2011 May;31(5):368-72. Epub 2010 Dec 9.
• The objective to compare alterations in the MCA PI and mean velocity (V mean) after laser surgery for twin-twin transfusion syndrome (TTTS).
• Despite the changes in the MCA PI after laser for TTTS, the MCA V (mean) remained constant.
• These findings may suggest some autoregulatory capacity in the cerebral vessels of the mid-trimester fetus.
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NEW APPLICATIONS
Umbilical artery notching:
• Cord entanglement
• True knot
• Cord stricture
• Velamentous insertion
• Tight nuchal cords
• Abnormal cord coiling
JUM 2002;21:857
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PLACENTA - 3D DOPPLER
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VASCULARIZATION INDEX (VI)
• VI = measures % of color pixels in ROI that represent flow
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FLOW INDEX (FI) & VASCULARIZATION FLOW INDEX (VFI)
• FI = measures intensity of color pixels in ROI
• VFI = combines % of color pixels and intensity in ROI (0-100 normalized)
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3-D CALCULATIONS
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J Ultrasound Med 26:1469-1477 • 0278-4297 Staging of Intrauterine Growth-Restricted Fetuses
Giancarlo Mari, MD, Farhan Hanif, MD, Kathrin Drennan, MD and Michael Kruger, MA
• The staging system proposed here may allow comparison of outcome data for IUGR fetuses and may be valuable in determining more timely delivery for these high-risk
fetuses.
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STAGING OF GROWTH RESTRICTED FETUS:
Intrauterine growth restriction was defined as the presenceof an estimated fetal weight below the 10th percentile. Intrauterine growth-restricted fetuseswere staged according to the following parameters, with the presence of any 1 parameter in a stageplacing the fetus in that stage
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STAGE I
• an abnormal umbilical artery or middle cerebral artery pulsatility
• index;
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STAGE II
an abnormalMCA PSV, absent/reversed diastolic velocityin the UA, UV pulsation and an abnormal DV PI(an absent DV A wave is considered part of thisstage)
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STAGE III
• reversed flow at the ductus venosus or reversed flow at the umbilical vein, an abnormal tricuspid E wave (early ventricular filling)/A wave (late ventricular filling) ratio, and tricuspid regurgitation.
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EACH STAGE DIVIDED IN A & B
• A is AMNIOTIC FLUID INDEX <5
• B is AMNIOTIC FLUID INDEX OF >5
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Staging of IntrauterineGrowth-Restricted Fetuses
Giancarlo Mari, MD, Farha n Hanif, MD,Kathrin Drennan, MD, Michael Kruger, MA
• The purpose of this study was 2-fold: (1) to assess the clinical relevance of a staging system for IUGR fetuses that would include ultrasonographic, Doppler, and clinical data; and (2) to
propose a classification that can be used for all types of IUGR fetuses
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• The rationale for the division of IUGR fetusesinto 3 stages was based on the results of previous studies in which we serially determined the changes of 15 Doppler parameters occurring in IUGR fetuses from the time the diagnosis was made up to delivery.On the basis of results of those studies, we should have divided the set of IUGR fetuses into 15 stages, but to keep the staging as a practical diagnostic tool, we
limited it to 3 stages.
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• Stage I fetuses have mild IUGR, and we
can treat these patients as outpatients
• stage II and III patients need to be admitted to
the hospital.
• Stage II patients are admitted for observation,
• stage III patients are at
• high risk for fetal death.
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• The major advantage of selecting the parameters included in this staging system is the ability to clearly track the progression of abnormal parameters that start at the UA and MCA and later to progressively extend the evaluation to the other parameters up to the time of fetal death if the fetus remain undelivered.
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• Another advantage is the simplicity of the system.
• Only 4 fetal vessels and 1 cardiac valve need
to be investigated with Doppler ultrasonography.
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Furthermore, it is not necessary to determine the
parameters reported for a certain stage if the
parameters of the previous stage are normal. For
example, if the UA and MCA PI values are normal,
it is not necessary to determine the parameters
of the next stage
This makes the staging
system easily applicable
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• Our data indicate that the staging system proposed
• here is applicable in pregnancies at gestational
• ages of both less than and greater than 30
• weeks, which makes the staging system reliable
• with regard to different gestational ages
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• If a fetus has an estimated fetal
• weight below the 10th percentile and both the
• UA PI and the MCA PI are normal, we classify it
• as stage 0.
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Time to deliver
Factors to decide time to deliver
• Degree of Prematurity
• NICU facility
• Degree of Hypoxia, acidemia, hepatic metabolic derangement
Challenge to weigh the risks and benefits of interventions
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Timing of delivery- TRUFFLE
The objective ofthis studywas to describeperinatal
morbidity andmortalityfollowingearly-
onsetfetalgrowth restriction basedontimeof antenatal diagnosis anddelivery
Outcomes
perinatal death
severe perinatal morbidity
Trial of randomised umbilical andfetalflow in EuropeLees et al, UltrasoundObstetGynecol2013
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TRUFFLE
Recruitment of very early FGRs26-32 weeks with EFW < 10thcentile and UA PI > 95thcentile
Delivery based on
ARM1 abnormal CTG/ reduced STV
ARM2 early DVchanges-PI>95thcentile
ARM3late DV changes absent orreverseda wave
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TRUFFLE-Implications for
management
< 30 weeks
Management based on DV
Neuro outcome better if
delivery is based on
absent or reversed ‘a’ wave
Or
If CTG STV is abnormal
After 30 weeks, deliver if:
30-32wks-reversed EDF
32-34wks- absent EDF
34-36wks- increased PI
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PREGNANCY MANAGEMENT
• Abnormal UA Doppler– Decreased diastolic flow
• Increase frequency of testing; consider deliver >37 weeks
– Absent end diastolic flow• Steroids; consider delivery at 34 weeks
– Reversed end diastolic flow• Steroids: consider delivery at 32 weeks
Am J Obstet Gynecol. 2012 Apr;206(4):300-8.
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PREGNANCY MANAGEMENT
• 37 or more: delivery if NRFS; elective delivery after 38-39 weeks
• <34 weeks:– Expectant management if reassuring fetal
status – Rx corticosteroids for fetal benefits
– Modified bed rest, smoking cessation, Rx hypertension
– Antepartum testing: NST/AFI & BPP twice weekly, daily kick counts, UA Doppler
– Abnormal UA Doppler: daily NST and at least twice weekly BPP for up to 2 weeks
– Non-reassuring status: evaluate for delivery
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PREGNANCY MANAGEMENT
• 34-37 weeks– Management individualized
– Antepartum testing: NST/AFI twice weekly, UA Doppler
– Non-reassuring status: evaluate for delivery
– Oligohydramnios and abnormal UA Doppler: more frequent antepartum testing but not delivery (unless non-reassuring status)
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When to deliver?
<28wksDifficult decisionCounselingChallenge to the neonatologist
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When to deliver?
>34weeks
Low threshold for delivery
Abnormal doppler
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When to deliver?
32-34weeks
Continue to monitor when high resistance in UA and cerebral redistribution
Absent or reversed EDV is an indication for
immediate delivey
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When to deliver?
28-32weeks
Absent or reversal of EDV in venousdoppler(DV)
Abnormal Biophysical profile
Spontaneous decelerations
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When to deliver?
<28weeks
Difficult decision
Parents to be extensively counseled
Challenge for the paediatriciansin terms of
prolonged care
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Planning mode of delivery
SGAumbilical artery AREDV
Cesareansection
SGAnormal umbilical artery Doppler or with abnormal umbilicalarteryPI butend–diastolic velocitiespresent
Induction can be offered continuousmonitoring
SGA with normaldoppler
Senior input about time / mode
Continuous CTG
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BERLIN C0NCENSUS
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ROAD TO DEATH
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Take home message
SGA is a complex diagnostic exercise and FGR is a significant perinatal problem
Distinction between growth restricted baby and a low growth potential baby is a critical issue
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Take home message
Majority occur in low risk pregnancies
Prospective screening of all pregnancies may help in predicting FGR- debatable
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Take home message
Commonly due to ischemic placental disease
No therapeutic intervention to reverse the process
Timing of delivery is crucial tooptimiseoutcome
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Take home message
Dating of pregnancy is vital
Serial scans may be required
Growth charts
Rule out underlying cause- aneuploidy and
infections in early onset FGR whendopplersare normal
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Take home message
Deliver at 34wks/ deterioration
Doppler particularly venousdoppleris the cornerstone of monitoring
Prepare thepaedsand the parents
Intervene before acidosis sets in
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CONCLUSIONS• Doppler ultrasound is integral part in management of
IUGR, fetal anemia, placental abnormalities, twins
• 3D Doppler is a unique technique that enables assessment of vascular signals within the whole investigated area.
• Homodynamic changes included in the process of placentation are one of the most exciting topics in the investigation of human development.
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WHEN DOPPLER STUDY IS
NORMAL
The diagnosis of IUGR is doubtful
(Brodoszki, et al., 2002)
It may be a constitutionally small normal
fetus (Burket et al, 1990, Pattnson, et al 1994)
Small fetus with normal Doppler left
unmonitored (Baschat and Weiner, 2000)
Expectant management on continued
surveillance (Harman and Baschat, 2003)
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If Doppler is
available
It may identify a fetus with IUGR
who registers later and you are
uncertain of the gestational age
Low-Risk
Suggestions
Doppler French Study Group
Br J Obstet Gynecol 1997, 104:419
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4 of our latest books released
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