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Eduard Gratacos
www.fetalmedicinebarcelona.org/
selective IUGR II (and III) !Expectant management and Cord Occlusion
BCNatal – Barcelona Center of Maternal-Fetal and Neonatal Medicine!Hospital Clinic and Hospital Sant Joan de Déu, University of Barcelona!
www.fetalmedicinebarcelona.org
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www.fetalmedicinebarcelona.org/
1. Diagnosis and types!!2. Expectant vs active management!
3. Results with Cord Occlusion!
4. Conclusions
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www.fetalmedicinebarcelona.org/
1. Diagnosis and types!!2. Expectant vs active management!
3. Results with Cord Occlusion!
4. Conclusions
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www.fetalmedicinebarcelona.org/
MC twins: apparent discrepancy in AF and/or fetal size Algorithm for differential diagnosis
EFW <P10 (+/- disc 25%)
• discordant for AF!• discordant for EFW
sIUGRyes
AF: > 8 cm (> 10 cm) / < 2cm!Clearly discordant bladders TTTSyes
no
noNothing for the moment!Close surveillance
Gratacos et al. Fetal Diagn Ther 2012
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GA @ delivery 29-32 weeks!Survival 50-65%!
Neurological damage 10-30%
Normally good prognosis
Quintero 03, Gratacós 04, Vanderheyden 05, Huber 06, Ishii 09
www.fetalmedicinebarcelona.org/
MC-sIUGR and UA Doppler in the IUGR fetus
No change in Doppler pattern from diagnosis (≈20w) to delivery!Lee 04, Vanderheyden 05, Gratacós 04, 07
TYPE I TYPE II TYPE III
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www.fetalmedicinebarcelona.org/
1. Diagnosis and types!!2. Expectant vs active management!
3. Results with Cord Occlusion!
4. Conclusions
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www.fetalmedicinebarcelona.org/
Parents’ wishes
Technical issues
sIUGR is not a unique disease as TTTS!DETERMINANTS OF MANAGEMENT
!!
Expectant !Cord Occlusion!
Laser!
Severity!GA / ️Discordance / REDF / DV-
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Active Management
www.fetalmedicinebarcelona.org/
Decision tree for counseling in sIUGR
1: DIAGNOSIS!sIUGR + no TTTS
2: sIUGR TYPE
I II III
Expectant + Follow-up 1/w
Expectant + Follow-up 1/w
3: SEVERITY!GA<24w /Disc >35%
AREDF /DV>p95
NO YES
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www.fetalmedicinebarcelona.org/
1. Diagnosis and types!!2. Expectant vs active management!
3. Results with Cord Occlusion!
4. Conclusions
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www.fetalmedicinebarcelona.org/
n=90 (2006-2013)!• <p10 + >25% discordance!• 38 type II / 52 type III!• 100% on severity criteria (GA<22w or Disc >35% or AREDF or DV>p95)!
• Entry in SGA sac (+/- amnioinfusion) OR septostomy + cord section
CORD OCCLUSION IN sIUGR
Median (range) GA at surgery (w) 20.7 (15-25)
Median (Range) duration (min) 23.5 (9-53)
Only-Mainly Bipolar / Laser (%) 94 % / 6 %
Entry in SGA sac 94%
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Pregnancy Outcomes
www.medicinafetalbarcelona.org/
0
8
16
24
32
40
GA @ delivery (w)
36,736,136,3
Overall Type II Type III
0
20
40
60
80
100
Survival AGA (%)
93,193,793,3
CORD OCCLUSION IN sIUGR
Miscarriage <24w 5.5 % (5/90)
Delivery < 32 w 12.2 % (11/90)
GA @delivery (w) 36.3 (15-25)
Survival
AGA 93.3 % (84/90)
Overall 47 % (84/180)
Birthweight (g) 2586 ± 865.3
Periventr. Leukomalacia 1.1 % (1/90)
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Pregnancy Outcomes
www.medicinafetalbarcelona.org/
CORD OCCLUSION IN sIUGR
Miscarriage <24w 5.5 % (5/90)
Delivery < 32 w 12.2 % (11/90)
GA @delivery (w) 36.3 (15-25)
Survival
AGA 93.3 % (84/90)
Overall 47 % (84/180)
Birthweight (g) 2586 ± 865.30
8
16
24
32
40
GA @ delivery* (w)
34,031,5
36,3
Parra (n=90)Chalouhi (n=24)Bebbington (n=22)
0
20
40
60
80
100
Survival AGA (%)
93,188,0
93,0
*Bebbington et al: Estimate.
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www.medicinafetalbarcelona.org/
0
8
16
24
32
40
GA @ delivery (w)
33,535,5
CO (n=136 - Parra, Chalouhi, Bebbington)Laser (n=47 - Quintero, Chalohuhi)
0
20
40
60
80
100
CO Laser
4654
19
3546
AGA SGA NS
Overall Survival 46% vs 54%
Survivors per 100 fetuses
0
20
40
60
80
100
Survival AGA (%)
69
91
0
20
40
60
80
100
Survival SGA (%)
38
0
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www.fetalmedicinebarcelona.org/
1. Clinical forms!!2. Expectant vs active management!
3. Results with Cord Occlusion!
4. Conclusions
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www.fetalmedicinebarcelona.org/
III: iAREDF
II: AREDF 1. Expectant management is associated with poor survival and neurological outcome!
2. Active management in sIUGR protects normal fetus but worsens that of IUGR.!
3. Final decision: balance between severity + parents’ wishes (+ rarely technical issues).!
4. Cord occlusion: more radical but >90% survival, reduces instances preterm birth and severe IUGR
Conclusions!Management of sIUGR II and III in MC twins
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www.medicinafetalbarcelona.org/
0
8
16
24
32
40
GA @ delivery (w)
33,535,5
CO (n=136 - Parra, Chalouhi, Bebbington)Laser (n=169 - Peeva, Quintero, Chalohuhi)
0
20
40
60
80
100
CO Laser
4654
19
3546
AGA SGA NS
Overall Survival 46% vs 54%
Survivors per 100 fetuses
0
20
40
60
80
100
Survival AGA (%)
69
91
0
20
40
60
80
100
Survival SGA (%)
38
0
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www.fetalmedicinebarcelona.org/
Poor prognosis: high risk of IUFD and neurological damage for both twins
Normally good prognosis
TYPE II TYPE IIITYPE I
EXPECTANT CORD OCCLUSION LASER
MODULATORS!• Severity!• Parents’ wishes!• Technical aspects
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www.fetalmedicinebarcelona.org/
Feasible 90%!More difficult than TTTS!• NO polihydramnios (amnioinfusion/
drainage required)!• equator often in smaller sac!• type and size of anastomoses
LASER THERAPY IN sIUGR
Quintero, Gratacos, Chaloui
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www.fetalmedicinebarcelona.org/
Expectant!(n=138)
Laser!(n=50)
Cord Occlusion!(n=98)
GA@delivery 29-32 32-35 33-37
Survival! ! AGA! ! IUGR
!70-85 %!40-85 %
!70-90 %!30-40 %
!>90 %!
0 %
Sequelae (*) !! AGA! ! IUGR
!15-35%!25-50%
!<5%!15%
!<5%!
-
Quintero 03, Gratacós 04-10, Vanderheyden 05, lshii 09, Chaloui 12, Parra 14 (*), Nicolaides 14(*)
(* unpublished data)
sIUGR in MC twins with abnormal Doppler (II and III)!pooled published data with different management schemes
(*limited info - small series)
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Fetal Diagn Ther 2014www.fetalmedicinebarcelona.org/
Type I!UA N
II!AREDV
III!iAREDV
Subtype ab!
AREDV / Disc>35%, DVpatol
ab!
AREDV / Disc>35%, DVpatol
Follow up 2w 1w 1w 1w 1w
Attitude Expectant Discuss expectant
Discuss therapy
Discuss expectant
Discuss therapy
Consider delivery !
(if not treated)34-35w 32w
30w DV>95!>26w if DV atrial flow neg
33-34w30w DV>95!>26w if DV atrial flow neg
sIUGR in MC pregnancy Tentative management scheme
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www.medicinafetalbarcelona.org/
0
8
16
24
32
40
GA @ delivery (w)
3333,536,3
CO (n=90 - Bcn)Laser type III (n=32 - Bcn)Laser type II (n= 135 - FMF)Laser II/III (n=23 - Paris)
0
20
40
60
80
100
Survival AGA (%)
7369
84
93
0
20
40
60
80
100
Survival SGA (%)
30
3937
0
0
20
40
60
80
100
CO Laser
4654
19
3546
AGA SGA NS
Overall Survival 46% vs 54%
Survivors per 100 fetuses
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www.medicinafetalbarcelona.org/
0
8
16
24
32
40
GA @ delivery (w)
33,535,5
CO (n=136 - Parra, Chalouhi, Bebbington)Laser (n=169 - Peeva, Quintero, Chalohuhi)
0
20
40
60
80
100
CO Laser
4654
19
3546
AGA SGA NS
Overall Survival 46% vs 54%
Survivors per 100 fetuses
0
20
40
60
80
100
Survival AGA (%)
69
91
0
20
40
60
80
100
Survival SGA (%)
38
0