DGF CME on 29th January 2018 Fetal Growth Restriction Evidence based management Obstetric Ultrasound , Doppler ,

1. D.G.F. CME ON
Ultrasound Tips On
Fetal Growth Restriction
29TH JANUARY 2018 at WOOD APPLE DELHI
Contributors
Dr. Kiran Aggarwal Dr. Sharda Jain Dr. Jyoti Agarwal

2. Ultrasound Tips On
Fetal Growth Restriction: Evidence Based
Dr. Jyoti Agarwal
Director : Lifecare Centre &
Lifecare IVF

3. Ultrasound
Tips On
FGR
Dr Jyoti Agarwal

4. Growth – dates uncorrected
Babies can come in different sizes!
Every fetus has a potential to grow
Failure to achieve growth potential- FGR

5. Babies come in different sizes!
• 52% of still births
• 72% of unexplained
fetal deaths
• 8-10 times Increased
Perinatal morbidity and
mortality
Inspite of considerable advances , FGR still remains
one of the main challenges in maternity care

6. In severe symmetrical FGR
karyotyping & infection screen
Symmetrical
FGR Asymmetrical
FGR
10
–
12
%
Poor prognosis
Good prognosis
Bad prognosis

7. In FGR : aim of delivery
A live fetus
Intact survivability !
Riskof intrauterine compromisehas tobe
weighed against the potential risksfrom
iatrogenic prematuredelivery
Best Time Is When Fetal Redistribution
Mechanism Starts Failing

8. Ultrasound has revolutionized the
practice of obstetrics
• It has high negative
predictive value to r/o FGR
• USG does not predict all cases
of FGR
• Conventional USG fails to
identify the onset of hypoxia
in fetus
• Cochrane database (2000)
reveals that there is 40 %
improvement in perinatal
mortality by judicious use of
doppler

9. Ultrasound helps to….
• Assign fetal age
• Assess fetal size
• Estimate fetal weight
• Exclude Anomalies
• Amniotic fluid
assessment
• Placental ultrasound
• Color Doppler
• Biophysical profile

10. Abdominal cirumference has the
highest sensitivity and greatest
negative predictive value for
diagnosing FGR

11. Growth – dates uncorrected
Routine Foetal Biometry
Based on customised Growth Curve “VISUAL EFFECT”

12. Timeline for fetal hypoxemia
Doppler ultrasound can predict fetal distress sooner than BPP

13. DOPPLER STUDY : GOLD STANDARD
To identify hypoxia & fetal adaptation
To plan timing of delivery

14. Highest accuracy is required in
assessment of the
Degree of Fetal Deterioration
Degree of fetal Hypoxia
- Fetal arterial doppler
Degree of fetal Acidemia
–Fetal Venous doppler
Each additional day gained in utero can
significantly increase neonatal survival

15. Uterine artery doppler
(As screening test 82% sensitivity)
• All Women at time of level II
anomaly scan Should be
offered uterine artery
doppler at 20 – 24 weeks of
gestation
• Women with abnormal
uterine artery doppler (PI
>1.45 & presence of diastolic
notch) should be referred for
umbilical artery doppler
from 26 – 28 wks of
pregnancy

16. First sign of hypoxia is picked up by
Umbilical Artery forward wave flow
1º trimester
Absent Diastolic
Flow
early 2ºtrimester
Low Diastolic Flow
late 2º and 3º trimester
Resistance further reduces
more diastolic flow

17. DECREASED EDF ABSENT EDF REVERSED EDF
Abnormal Umb. A doppler appears when at least
60 % of the placental vascular bed is obliterated
PositiveDiastolic Flow 10 - 12% Hypoxic
00% Acidemic
Absent/ Reverse Diastolic
Flow
80% Hypoxic
40 – 45 % Acidemic

18. Umbilical artery doppler should be the
primary surveillance tool
• If umbilical artery flow is normal repeat every 15
days
• If abnormal repeat it twice weekly if end diastolic
velocity is present
• Should be done daily with absent or reversed end
diastolic velocity
• In low risk , no conclusive evidence that routine
umbilical artery doppler benefits either mother or baby

19. FETAL ADAPTATION
BLOOD FLOW
In order to prevent hypoxic injury

20. Overstressed fetus can lose the “brain sparing effect”
Disappearance of brain sparing effect
very critical event Precedes Fetal Death
MCA has tremendous implication for determining the
proper timing of delivery

21. With worsening placental vascular insufficency
• “a” wave velocity in DV doppler reduces &
finally reverses b’cos of increased afterload &
preload
• Has excellent predictive value for acidemia
• In preterm fetus it is used to time delivery

22. A retrograde “a - wave” and pulsatile flow in umbilical
vein signifies the onset of overt fetal cardiac
compromise
Double pulsatile patternEND POINT
Cardiac Failure : Impending Death

23. Good correlation Between Doppler & Hypoxia
Umbilical artery
50% placenta is not functioning
Mild Hypoxia
MCA
> 70% placenta not functioning
Compensatory redistribution
Moderate Hypoxia
DV > 90% placenta not functioning
Failure of Compensatory redistribution
Severe Hypoxia & acidemia
IMPENDING DEATH

24. Gestational age at decompensation is the
primary determinant of perinatal survival
Ft < 32
weeks
• Every week gained improves outcome by 40%
• Here venous dopplers help delay delivery
32 – 34
wks
• Deliver once Umb A ABSENT / REDV
At
term
• Prompt delivery at 37 wks of gestation
• Even when Umb.AD is normal
Steroid cover

25. Intervene Timely

27. THANK YOU
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