Intra Uterine Growth Restriction (IUGR) and SGA: Doppler Management and Prediction of Outcome Ryan Saktika Mulyana, dr, M.Biomed, SpOG(K) Maternal and Fetal Medicine, Obstetrics and Gynecology Department, Udayana University Hospital, Udayana University

1. Intra Uterine Growth Restriction (IUGR) and SGA:
Doppler Management and Prediction of Outcome
Ryan Saktika Mulyana, dr, M.Biomed, SpOG(K)
Maternal and Fetal Medicine, Obstetrics and Gynecology Department,
Udayana University / Udayana University Hospital

2. Current challenges in the clinical
management of IUGR and SGA
IUGR vs SGA
Accurate diagnosis of the
truly growth-restricted fetus
Doppler study vs No
Selection of appropriate fetal
surveillance
Conservative vs delivery
Optimizing the timing of
delivery.

3. Doppler Umbilical
artery (UA), middle
cerebral artery (MCA)
dan Ductus Venosus
(DV) for
nonanomalous fetuses
with suspected IUGR
Synthesize and assess
the strength of
evidence of the
current literature
Recommendations
regarding antepartum
management of the
pregnancies
Pemeriksaan Doppler pada IUGR

4. IUGR VS SGA
IUGR
SGA
1. Outcome
2. Manajemen
3. Redistribusi Hemodinamik

5. Pregnancies with IUGR (irrespective of whether there is
coexistent pre-eclampsia or not), there are atheromatous-like
lesions that completely or partially occlude the spiral arteries;
these changes are not present in pregnancies with pre-eclampsia
in the absence of IUGR
Sheppard BL, Bonnar J. An ultrastructural study of utero-placental spiral
arteries in hypertensive and normotensive pregnancy and fetal growth
retardation. Br J Obstet Gynaecol 1981;88:695–705

6. IUGR onset dini VS IUGR Onset lambat
Berat Ringan
Berhubungan dgn PREEKLAMPSIA (50%) Berhubungan dgn PREEKLAMPSIA (10%)
Gangguan placenta berat Gangguan placenta ringan
Immature fetus: high tolerance to hypoxia Mature fetus: Lower tolerance to hypoxia
Mortality : High
Morbidity : High
Prevalence : 20-30%
Mortality : Low
Morbidity : High (longterm)
Prevalence : 70-80%
DINI (32-34 wks) LAMBAT (>34 wks)

7. Fetal deterioration and monitoring
Early Onset Vs Late Onset

8. Placental disease
Increased impedance
Hypoxia
Centralization
Advanced hypoxia/acidosis
Reduced cardiac compliance
Serious injury
Death
UtA PI >p95
CPR <p5
Chronic/diagnostic markers (Weeks) Acute/prognostic markers (7–10 days)
UA PI >p95 UA AEDV UA REDV
MCA PI <p5 AoI PI >p95
DV PI >p95 DV rev. atrial
cCTG STV <3 ms
BPP <4
CTG decelerations
Growth restriction

9. Placental disease
Increased impedance
Hypoxia
Centralization
Advanced hypoxia/acidosis
Reduced cardiac compliance
Serious injury
Death
UtA PI >p95
CPR <p5
Chronic/diagnostic markers (Weeks) Acute/prognostic markers (7–10 days)
UA PI >p95 UA AEDV UA REDV
MCA PI <p5 AoI PI >p95
DV PI >p95 DV rev. atrial
cCTG STV <3 ms
BPP <4
CTG decelerations
Growth restriction
Acute deterioration (hours)

10. AGA dengan
Normal PI AU
SGA dengan
Normal PI AU
Good
Bad

11. Pemeriksan Doppler AU mampu mengidentifikasi gangguan
plasenta yang berat, namun gagal dalam mendeteksi
gangguan plasenta yang ringan
Doppler AU tidak dapat digunakan lagi sebagai kriteria
tunggal untuk membedakan IUGR dari SGA
Oros D, et al: Longitudinal changes in uterine, umbilical and fetal cerebral Doppler indices in
late-onset small-for-gestational age fetuses. Ultrasound Obstet Gynecol 2011; 37: 191–195

12. ManagementIUGR dan SGA
IUGR/SGA
Waktu persalinan
dan cara persalinan
Onset IUGR
Deteriorisasi

13. UtADoppler
ArteriUterina
Prinsip Pengukuran
1 Kemampuan untuk mendapatkan hasil
dari pemeriksaan doppler Arteri
uterina ini adalah 95-98%
2
Merupakan cabang arteri hipogastrika
sebelum masuk ke uterus pada
uteroservikal junction

14. Progressive decrease in impedance with advancing gestational age
Doppler velocimetry of the uterine arteries
Decreasing vascular impedance is
reflected by increased flow in diastole
and in disappearance of the notch
Notched uterine artery
Doppler waveform and low
diastolic flow is evident due to
high vascular impedance.

16. Adanya persisten notching pada arteri uterina
menentukan adanya abnormalitas aliran arteri
uterina
Penilaian Notching sangatlah subjektif sehingga
disarankan untuk tetap menghitung penilain PI
UtA (abnormal jika nilainya >95th persentil)

17. Studies in women with hypertensive disease of pregnancy have reported that, in
those with increased impedance (increased resistance index or the presence of an
early diastolic notch), compared to hypertensive women with normal flow
velocity waveforms, there is a higher incidence of pre-eclampsia, intrauterine
growth restriction, emergency Cesarean delivery, placental abruption,
shorter duration of pregnancy and poorer neonatal outcome
Campbell S, Griffin DR, Pearce JM, Diaz-Recasens J, Cohen-Overbeek T,Wilson K, Teague MJ.
New Doppler technique for assessing uteroplacental blood flow. Lancet 1983;26:675–7

18. DopplerAU
ArteriUmbilikalis
Prinsip Pengukuran
1 Transduser biasanya “pencil-
shaped probe”
2
Identifikasi tali pusat yang
free-floating
3 Aktifkan collor doppler pada
arteri dan vena umbilikalis
4 Lokasi pengambilan sampling
menentukan gambaran yang
didapat

19. To optimize reproducibility, we suggest interrogating the umbilical artery at the abdominal cord insertion
Close to the
placenta
(higher end-diastolic
flow velocity)
The fetal end
(lower end-diastolic
flow velocity)
free floating cord

20. Pemeriksaan Doppler arteri umbilikalis pada kehamilan yang dicurigai IUGR
menunjukkan secara signifikan terhadap penurunan induksi persalinan
(relative risk [RR], 0.89; 95% CI, 0.80–0.99), Persalinan SC (RR, 0.90; 95% CI,
0.84–0.97), dan Kematian perinatal (RR, 0.71; 95% CI, 0.52–0.98; 1.2% vs
1.7%; number needed to treat = 203; 95% CI, 103–4352)
Compared to not using this type of Doppler, the use of umbilical artery Doppler
studies in women with suspected IUGR is associated therefore with maternal and
perinatal benefits
American College of Obstetricians and Gynecologists. Intrauterine growth
restriction; ACOG practice bulletin no. 12. (Level III)ACOG, Washington, DC

22. Doppler AU pada KRT (IUGR) menurunkan kematian perinatal sampai 29% (2-48%)
AEDF atau REDF spektrum terakhir dari abnormalitas doppler UA,
perburukan yang terjadi 1 minggu sebelum terjadinya deteriorasi akut
>70% villi di plasenta
mengalami Obliterasi
represents an advanced stage of placental
compromise

23. http://perinatology.com/calculators/umbilicalartery.htm

24. Patology Plasenta Pada kasus IUGR
• 60% pembuluh darah plasenta mengalami obliterasi
• absent end-diastolic have more fetal stem vessels with
medial hyperplasia and luminal obliteration
• Capillary loops in placental terminal villi are decreased in
number, they are longer and they have fewer branches
than in normal pregnancies
Impedance Meningkat
Absent

25. Mean placental weight is reduced and the cross-
sectional diameter of terminal villi is shorter
Poorly vascularized terminal villi, villous stromal
hemorrhage, ‘hemorrhagic endovasculitis’ and
abnormally thin-walled fetal stem vessels
Reverse
Waktu median antara AEDF degan onset deselerasi adalah 12 hari (0-49 hari)
Todros T, Sciarrone A, Piccoli E, Guiot C, Kaufmann P, Kingdom J. Umbilical Doppler waveforms and placental villous
angiogenesis in pregnancies complicated by fetal growth restriction. Obstet Gynecol 1999;93:499–503

26. MCA
MiddlecerebralArtery
Prinsip Pengukuran
1 Potongan transverse kepala
fetus setinggi basis tulang
kepala/ skull
2
Proximal dan Distal arteri
cerebral media terlihat secara
longitudinal
3 Pengambilan sampel dilakukan
pada proksimal dari pembuluh
darah yang paling dekat dgn
sirkulus willis.

27. PSV MCA mungkin suatu prediktor yang lebih baik
dalam menilai IUGR dibandingkan PI (needed to
confirm this finding)
Pengukuran PSV MCA membutuhkan pengaturan
sudut kurang dari 30 derajat; optimalnya mendekati
0 derajat, sedangkan pengukuran PI tidak
memerlukan pengaturan sudut
PSV MCA versus PI MCA

28. Hipoxemia
Brain
Heart
Adrenal
1 Peningkatan end-diastolic flow
velocity (low PI MCA),Titik nadir
terjadi 2 minggu sebelum janin
memburuk (Arduini et al)
2 CPR is <5th percentile for
gestational age
Brain – Spairing Reflex

29. Pemeriksaan Doppler MCA (Middle cerebral artery) telah digunakan untuk
mengidentifikasi fetus IUGR yang beresiko mengalami SC akibat
FHB yang abnormal dan asidosis neonatus
Follow up jangka panjang terhadap fetus IUGR dengan normal arteri umbilikalis
namun doppler PI MCA < 5th persentil didapatkan fetus beresiko tinggi mengalami
gangguan perkembangan neurodevelopmental
American College of Obstetricians and Gynecologists. Intrauterine growth
restriction; ACOG practice bulletin no. 12. (Level III)ACOG, Washington, DC

30. pada populasi umum disebutkan bahwa CPR yang abnormal
dapat memprediksi keadaan perburukan neurobehavioral
pada usia 18 bulan setelah lahir
Roza SJ, et al: What is spared by fetal brainsparing? Fetal circulatory redistribution and behavioral
problems in the general population. Am J Epidemiol 2008; 168: 1145–1152.

31. DV
Doppler Ductus Venosus
Prinsip Pengukuran
1 Doppler waveforms are
obtained from the ductus
venosus in a transverse or
sagittal view of the fetal
abdomen at the level of the
diaphragm
2
Variable high flow velocities,
reflected as a mixture of colors on
color Doppler imaging (aliasing)

32. Ductus venosus Doppler
waveforms are biphasic in
shape with the first peak
corresponding to ventricular
systole, the second peak
during passive filling in
ventricular diastole, followed
by a nadir in late diastole with
atrial contraction
Gelombang khas untuk aliran darah DV

33. DV adalah parameter Doppler tunggal terkuat yang
memprediksi risiko jangka pendek kematian janin pada
IUGR onset dini
Absent atau reversed velocities selama kontraksi atrium
dikaitkan dengan kematian perinatal mulai dari 40-100%
pada IUGR onset dini
Abnormalitas DV ini dianggap cukup untuk
merekomendasikan persalinan pada usia kehamilan
berapa pun
Absent DV
Reverse DV

34. 50% kasus, DV abnormal
mendahului hilangnya
variabilitas jangka pendek
(STV) pada pemeriksaan
cCTG)
90% kasus mengalami
abnormalitas pada 48-72
jam sebelum perubahan
biophysical profil (BPP)
BPP
Biophysical Profile

36. KonsepDiagnosisdanPenentuan
PrognosisIUGRdanSGA
1
2
3
Janin teridentifikasi kecil (mis. EFW <10th persentil), lakukan
pengukuran UtA PI, UA PI, MCA PI dan CPR untuk
mengklasifikasikan IUGR atau janin SGA
Janin dengan IUGR, maka perubahan Doppler
dan cCTG wajib diperiksa untukmenentukan
tingkat deteriorisasi janin
Manajemen berdasarkan pertimbangan
resiko dan prognosis

37. Stage IV: DV absent/reversed EDV (persisting 12 h apart) or
pathological CTG (reduced STV or deceleration pattern)
Stage III: DV PI > 95th centile or
UA reversed EDV (both persisting 12 h apart)
Stage II: UA absent EDV atau AoI reverse diastolik Velocities
(both persisting 12h apart)
Stage I: EFW <3rd centile or CPR <5th centile or
MCA PI<5th centile (both persisting 12 h apart) or
mean UtA PI >95th centile
SGA ≥ 40 wks
≥ 26 wks
≥ 30wks
≥ 34 wks
≥ 37 wks
yes
yes
yes
yes
yes
yes
yes
yes
ElectivecesareansectionLaborinduction
No
No
No
No
No
No
No
No
No
Repeat in 1 weeks
Repeat in 2-3 days
Repeat in 24-48 hours
Repeat in 12 -24 hours
yes

38. Pemeriksaan Doppler arteri umbilkal diantara kehamilan resiko
tinggi yang dicurigai IUGR signifikan menurunkan labor induction,
cesarean delivery, dan kematian perinatal (1.2% vs 1.7%; relative
risk, 0.71; 95% confidence interval, 0.52–0.98).
Results and Recommendations

39. Parameter tunggal terbaik yang dapat digunakan adalah
Doppler Cerebro Placental Ratio (CPR), dihitung dengan
membagi PI MCA dengan PI UA.
ketika salah satu peeriksaan CPR, UtA PI atau EFW <p3 tidak
normal maka risiko luaran perinatal yang buruk akan
meningkat
Results and Recommendations