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<ul>Doppler Ultrasound in the Management of Fetal Growth Restriction </ul><ul>Chukwuma I. Onyeije, M.D. </ul><ul>Atlanta P...
<ul>For your convenience a copy of this lecture is available for review and download at http://onyeije.net/present </ul>
<ul>Intrauterine Growth R estriction - IUGR Small for Gestational Age - SGA Fetal growth restriction - FGR </ul><ul>Termin...
<ul>Definitions   </ul><ul><li>Intrauterine growth retardation (IUGR)   </li></ul><ul><ul><li>Fetus is at or below the 10t...
Fetus is subjected to pathology that restricts  its ability to grow. </li></ul></ul><ul><li>Small for Gestational Age: </l...
<ul>Traditional Classification of IUGR   </ul><ul>Symmetrical </ul><ul>A symmetrical </ul><ul>Fetal brain is abnormally la...
<ul>In a normal infant, the brain weighs about three times more than the liver. In asymmetrical IUGR, the brain can weigh ...
<ul>Normal Small Fetus  </ul><ul>Abnormal Small Fetus </ul><ul>Growth Restricted Fetus </ul><ul>Functional Classification ...
<ul>Normal Small Fetus:  </ul><ul><ul><ul><li>No Structural abnormality.  Normal umbilical Doppler.  Normal AFI.
Less than 10 th  percentile.
Good prognosis.  No increased risk.  No special care provided. </li></ul></ul></ul><ul>. </ul><ul>Functional Classificatio...
<ul>Abnormal Small Fetus: </ul><ul><ul><ul><li>Chromosomal abnormality or structural defect with small size.
Poor prognosis. </li></ul></ul></ul><ul>Functional Classification   </ul>
<ul>Growth Restricted Fetus: </ul><ul><ul><ul><li>Small due to placental dysfunction
Variable prognosis.
Appropriate and timely treatment can improve outcome. </li></ul></ul></ul><ul>Functional Classification   </ul>
<ul>Maternal Risk Factors </ul><ul><li>Multiple gestation
Drug exposure
Cardiovascular disease
Kidney disease
Chronic infections </li></ul><ul><ul><li>UTI, Malaria, TB, genital infections </li></ul></ul><ul><li>Autoimmune disease </...
<ul>Fetal Risk Factors </ul><ul><li>TORCH infections
Fetal anomalies
Aneuploidy
Skeletal Dysplasia
Hypoxia </li></ul>
<ul>Placental Factors </ul><ul><li>Uteroplacental insufficiency </li></ul><ul><ul><li>Improper placentation in the first t...
Abnormal insertion of placenta.
Reduced maternal blood flow to the placenta. </li></ul></ul><ul><li>Fetoplacetal insufficiency due to-. </li></ul><ul><ul>...
Decreased placental functioning mass-. </li></ul></ul><ul><ul><ul><li>Small placenta, abruptio placenta, placenta previa, ...
<ul>Diagnosis of IUGR </ul><ul><li>Difficult diagnosis
Need to evaluate risk factors
Serial ultrasounds important
Dating is important
Ultrasound signs </li></ul><ul><ul><li>Inadequate fetal interval growth.
Reduced AFI.
Placental calcification. </li></ul></ul>
<ul>The Growth Restricted Neonate </ul><ul><li>Normal & IUGR Newborn babies </li></ul><ul><li>Normal & IUGR Placentas </li...
<ul>The Growth Restricted Placenta </ul>
<ul>S urveillance   </ul><ul><li>Duration:  Until delivery occurs </li></ul><ul><li>Reason :  To identify further progress...
 
<ul>Doppler ultrasonography was first used to study flow velocity in the fetal umbilical artery in 1977 </ul><ul>Doppler I...
<ul>DOPPLER WORKS LIKE AN ECHO T1  :  time of omitted signal   . T2  :  time of returned signal . </ul><ul>T2 – T1 =  time...
<ul>pulse repetition frequency </ul><ul>(T2 –T1)  phase shift  with known  beam / flow angle  can calculate flow velocity ...
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Doppler ultrasound in the management of fetal growth restriction and IUGR

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Doppler ultrasound in the management of fetal growth restriction or IUGR

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  • Stem cells are “non-specialized” cells that have the potential to form into other types of specific cells, such as blood, muscles or nerves. They are unlike 'differentiated' cells which have already become whatever organ or structure they are in the body. Stem cells are present throughout our body, but more abundant in a fetus.
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  • After 6 months of offering stem cell therapy in combination with the venous angioplasty liberation procedure, patients of CCSVI Clinic have reported excellent health outcomes. Ms. Kasma Gianopoulos of Athens Greece, who was diagnosed with the Relapsing/Remitting form of MS in 1997 called the combination of treatments a “cure”. “I feel I am completely cured” says Ms. Gianopoulos, “my symptoms have disappeared and I have a recovery of many functions, notably my balance and my muscle strength is all coming (back). Even after six months, I feel like there are good changes happening almost every day. Before, my biggest fear was that the changes wouldn’t (hold). I don’t even worry about having a relapse anymore. I’m looking forward to a normal life with my family. I think I would call that a miracle.”
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Doppler ultrasound in the management of fetal growth restriction and IUGR

  1. 1. <ul>Doppler Ultrasound in the Management of Fetal Growth Restriction </ul><ul>Chukwuma I. Onyeije, M.D. </ul><ul>Atlanta Perinatal Associates </ul>
  2. 2. <ul>For your convenience a copy of this lecture is available for review and download at http://onyeije.net/present </ul>
  3. 3. <ul>Intrauterine Growth R estriction - IUGR Small for Gestational Age - SGA Fetal growth restriction - FGR </ul><ul>Terminology </ul>
  4. 4. <ul>Definitions </ul><ul><li>Intrauterine growth retardation (IUGR) </li></ul><ul><ul><li>Fetus is at or below the 10th percentile for EGA
  5. 5. Fetus is subjected to pathology that restricts its ability to grow. </li></ul></ul><ul><li>Small for Gestational Age: </li></ul><ul><ul><li>A “small” but otherwise healthy fetus. </li></ul></ul><ul><li>Low Birth weight (LBW) </li></ul><ul><ul><li>Birth weight of less than 2500 gms which could be due to IUGR or prematurity </li></ul></ul>
  6. 6. <ul>Traditional Classification of IUGR </ul><ul>Symmetrical </ul><ul>A symmetrical </ul><ul>Fetal brain is abnormally large when compared to the body Occurs when the fetus experiences a problem during later development </ul><ul>Fetal head and body are proportionately small . Occurs with early developmental problems . </ul>
  7. 7. <ul>In a normal infant, the brain weighs about three times more than the liver. In asymmetrical IUGR, the brain can weigh five or six times more than the liver. </ul>
  8. 8. <ul>Normal Small Fetus </ul><ul>Abnormal Small Fetus </ul><ul>Growth Restricted Fetus </ul><ul>Functional Classification </ul>
  9. 9. <ul>Normal Small Fetus: </ul><ul><ul><ul><li>No Structural abnormality. Normal umbilical Doppler. Normal AFI.
  10. 10. Less than 10 th percentile.
  11. 11. Good prognosis. No increased risk. No special care provided. </li></ul></ul></ul><ul>. </ul><ul>Functional Classification </ul>
  12. 12. <ul>Abnormal Small Fetus: </ul><ul><ul><ul><li>Chromosomal abnormality or structural defect with small size.
  13. 13. Poor prognosis. </li></ul></ul></ul><ul>Functional Classification </ul>
  14. 14. <ul>Growth Restricted Fetus: </ul><ul><ul><ul><li>Small due to placental dysfunction
  15. 15. Variable prognosis.
  16. 16. Appropriate and timely treatment can improve outcome. </li></ul></ul></ul><ul>Functional Classification </ul>
  17. 17. <ul>Maternal Risk Factors </ul><ul><li>Multiple gestation
  18. 18. Drug exposure
  19. 19. Cardiovascular disease
  20. 20. Kidney disease
  21. 21. Chronic infections </li></ul><ul><ul><li>UTI, Malaria, TB, genital infections </li></ul></ul><ul><li>Autoimmune disease </li></ul>
  22. 22. <ul>Fetal Risk Factors </ul><ul><li>TORCH infections
  23. 23. Fetal anomalies
  24. 24. Aneuploidy
  25. 25. Skeletal Dysplasia
  26. 26. Hypoxia </li></ul>
  27. 27. <ul>Placental Factors </ul><ul><li>Uteroplacental insufficiency </li></ul><ul><ul><li>Improper placentation in the first trimester.
  28. 28. Abnormal insertion of placenta.
  29. 29. Reduced maternal blood flow to the placenta. </li></ul></ul><ul><li>Fetoplacetal insufficiency due to-. </li></ul><ul><ul><li>Vascular anomalies of placenta and cord.
  30. 30. Decreased placental functioning mass-. </li></ul></ul><ul><ul><ul><li>Small placenta, abruptio placenta, placenta previa, postdates </li></ul></ul></ul>
  31. 31. <ul>Diagnosis of IUGR </ul><ul><li>Difficult diagnosis
  32. 32. Need to evaluate risk factors
  33. 33. Serial ultrasounds important
  34. 34. Dating is important
  35. 35. Ultrasound signs </li></ul><ul><ul><li>Inadequate fetal interval growth.
  36. 36. Reduced AFI.
  37. 37. Placental calcification. </li></ul></ul>
  38. 38. <ul>The Growth Restricted Neonate </ul><ul><li>Normal & IUGR Newborn babies </li></ul><ul><li>Normal & IUGR Placentas </li></ul>
  39. 39. <ul>The Growth Restricted Placenta </ul>
  40. 40. <ul>S urveillance </ul><ul><li>Duration: Until delivery occurs </li></ul><ul><li>Reason : To identify further progression of the disease process that would jeopardize the fetus. </li></ul><ul><li>Modalities : NST, AFI, Doppler, BPP </li></ul>
  41. 42. <ul>Doppler ultrasonography was first used to study flow velocity in the fetal umbilical artery in 1977 </ul><ul>Doppler In IUGR </ul>
  42. 43. <ul>DOPPLER WORKS LIKE AN ECHO T1 : time of omitted signal . T2 : time of returned signal . </ul><ul>T2 – T1 = time difference or phase shift . </ul><ul>The Doppler frequency is obtained from phase shift. AS TIME DIFFERENCE DECREASE THE DOPPLER FREQUENCY INCREASE . </ul>
  43. 44. <ul>pulse repetition frequency </ul><ul>(T2 –T1) phase shift with known beam / flow angle can calculate flow velocity . </ul><ul>T1 </ul><ul>T2 </ul><ul>Basic Principals </ul>
  44. 45. <ul>The time difference or phase shift can be processed to produce either colorflow display or a Doppler sonogram </ul><ul>Basic Principles </ul>
  45. 46. <ul>The angle q between the beam and the direction of flow is VERY important in the use of Doppler ultrasound. </ul><ul>Freq. </ul><ul>q </ul><ul>The angle of insonation </ul><ul>Flow velocity </ul><ul>3 </ul><ul>2 </ul><ul>1 </ul><ul>Factors affecting doppler frequency </ul>
  46. 47. <ul>Why the Different Waveforms? </ul><ul>B eam (A) is more aligned than (B) </ul><ul>The beam/flow angle at (C) is almost 90° and there is a very poor Doppler signal </ul><ul>The flow at (D) is away from the beam and there is a negative signal. </ul>
  47. 48. <ul>Aliasing </ul><ul>If a second pulse is sent before the first is received, the receiver cannot discriminate between the reflected signal from both pulses and aliasing occur. </ul>
  48. 49. <ul>So to eliminate aliasing The pulse repetition frequency or scale is set appropriately for the flow velocities </ul><ul>Aliasing </ul>
  49. 50. <ul>Umbilical artery Doppler </ul>
  50. 51. <ul>Doppler indices </ul>
  51. 52. <ul>UMBILICAL ARTERY FLOW Arterial flow has a saw-tooth pattern of arterial flow in one direction Venous blood flow is continuous in the other direction. </ul><ul>Umbilical artery </ul>
  52. 53. <ul>FACTORS AFFECTING UMBILICAL ARTERY DOPPLER FLOW VELOCITY WAVEFORMS* </ul>
  53. 54. <ul><li>Doppler of the Umbilical Artery </li></ul><ul>An increasing trend in Doppler suggests deteriorating condition . </ul>
  54. 55. <ul>Middle cerebral artery doppler </ul>
  55. 56. <ul>The middle cerebral artery can be seen as a major lateral branch of the circle of Willis It runs anterolaterally at the borderline between the anterior and the middle cerebral fossae </ul><ul>Middle cerebral artery </ul>
  56. 57. <ul>Redistribution of blood flow occurs as an early stage in fetal adaptation   to  hypoxemia    ( brain-sparing reflex)  Increased blood flow to protect the brain, heart, and adrenals Reduced flow to the peripheral and placental circulations           </ul><ul>Middle cerebral artery </ul>
  57. 58. <ul>MCA Doppler wave form of early stage of fetal hypoxemia   </ul><ul>increased end-diastolic flow in the middle cerebral artery (lower MCA pulsatility index or resistance index )   Average of both MCAs must be calculated for more precise result </ul>
  58. 59. <ul>Middle Cerebral Artery </ul><ul>Flow velocity waveform in the fetal middle cerebral artery in a severely anemic fetus at 22 weeks (left) and in a normal fetus (right). In fetal anemia, blood velocity is increased </ul>
  59. 60. <ul>When the fetus is hypoxic, the cerebra arteries tend to become dilated in order to preserve the blood flow to the brain and The systolic to diastolic ratio will decrease (due to an increase in diastolic flow) </ul><ul>Middle Cerebral Artery </ul>
  60. 61. <ul>MCA Doppler Calculations </ul><ul>The brain sparing effect is manifested by : A DECREASED PULSATILITY INDEX (PI): THE PULSATILITY INDEX = ([peak systolic velocity minus lowest diastolic velocity] divided by [mean velocity]) -or- S-D / A MCA DOPPLER CALCULATOR: </ul>
  61. 62. <ul>Doppler ultrasound for the fetal assessment in high-risk pregnancies </ul><ul><li>A reduction in perinatal deaths.
  62. 63. Fewer inductions of labour .
  63. 64. Fewer admissions to hospital .
  64. 65. no report of adverse effects .
  65. 66. No difference was found for fetal distress in labour .
  66. 67. No difference in caesarean delivery . </li></ul>
  67. 69. <ul>The 4 “Ts” Recalled </ul><ul>“ THROMBIN ” </ul><ul>Check labs if suspicious . </ul>
  68. 70. <ul>Short Term Risks of IUGR </ul><ul><li>Increased perinatal morbidity and mortality. </li></ul><ul><ul><li>Intra uterine / Intrapartum death.
  69. 71. Intrapartuum foetal acidosis characterized by-. </li></ul></ul><ul><ul><ul><li>Late deceleration.
  70. 72. Severe variable deceleration.
  71. 73. Beat to beat variability.
  72. 74. Episodes of bradicardia. </li></ul></ul></ul><ul><ul><li>Intrapartum foetal acidosis may occur in as many as 40 % of IUGR, leading to a high incidence of LSCS.
  73. 75. IUGR infants are at greater risk of dying because of neonatal complications- asphyxia, acidosis, meconium aspiration syndrome, infection, hypoglycemia , hypothermia , sudden infant death syndrome.
  74. 76. IUGR infants are likely to be susceptible to infections because of impaired immunity </li></ul></ul>
  75. 77. <ul>Long term Prognosis </ul><ul><li>Babies who suffer from IUGR are at an increased risk for death , low blood sugar , low body temperature , and abnormal development of the nervous system. These risks increase with the severity of the growth restriction.
  76. 78. The growth that occurs after birth cannot be predicted with certainty based on the size of the baby when it is born.
  77. 79. Infants with asymmetrical IUGR are more likely to catch up in growth after birth than are infants who suffer from prolonged symmetrical IUGR.
  78. 80. If IUGR is related to a disease or a genetic defect, the future of the infant is related to the severity and the nature of that disorder. </li></ul>
  79. 81. <ul>Long term Prognosis </ul><ul><li>IUGR infants are more likely to remain small than those of normal birth weight. They will need the special attention of primary health, nutrition and social services during infancy and early childhood.
  80. 82. Implication of IUGR can be life long affecting: </li></ul><ul><ul><li>Body size growth , composition and physical performance .
  81. 83. Immunocompetence. </li></ul></ul><ul><li>It appears to predispose to adult adult-onset, degenerative disease s like maturity onset diabetes and cardiovascular diseases.
  82. 84. Each case is unique. C an not reliably predict an infant's future progress. </li></ul>

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