FMFbarcelona2024 - Eduard Gratacós - MANAGEMENT OF FETAL GROWTH RESTRICTION.pdf

www.fetalmedicinebarcelona.org/
Eduard Gratacós
MANAGEMENT OF
FETAL GROWTH RESTRICTION
BCNatal – Barcelona Center of Maternal-Fetal and Neonatal Medicine
Hospital Clínic and Hospital Sant Joan de Déu, Universitat de Barcelona

1. Identification of (isolated) “small fetus”
2. Distinguish SGA from FGR (and severity stage)
3. Determine follow-up and timing of delivery

2. Distinguish SGA vs FGR (and severity stage)

PROTOCOL STEP #2a:
SMALL FETUS: IS IT FGR OR SGA?
PLACENTAL DISEASE HYPOXIA ACIDOSIS SERIOUS INJURY DEATH
cardiac ischemia
Diastolic failure
Systolic cardiac
failure
Centralization
Increment uterine and
placental impedance
Measures
EFW
Dopplers
UA
MCA
(CPR)
UtA
Diagnostic/chronic markers
DIFFERENCE
FGR VS SGA
INDEPENDENT OF
EARLY OR LATE

UtA
>p95
CPR
<p5
(or UA>95)
EFW/AC CENTILE <3
Figueras & Gratacos 2014
FGR = EFW/AC < p10 + any of
Predictive value
individual criteria
for FGR
Meler 2020

UtA
>p95
CPR
<p5
EFW CENTILE <3
FGR = EFW < p10 + any of
Ratio sFflt1/PlGF >38 if available
or

cardiac ischemia
Diastolic failure
Systolic cardiac
failure
Centralization
Increment placental
impedance
FGR: DEGREE OF FETAL DETERIORATION
(timing of delivery and next evaluation)
DIFFERENCE
FGR VS SGA
Prognostic/Acute markers
INDICATION ABOUT THE SHORT-TERM RISK
OF IUFD/BRAIN INJURY
BPP < 6
cCTG: reduced STV
CGTdec
(NO PLACENTAL DISEASE)
PROTOCOL STEP #2b:
IF FGR: HOW SEVERE IT IS?

Ferrazzi 2002, Baschat 2003, Hecher 2003, Baschat 2007
Grivell 2009, Kafur 2008, Lalor 2010, Crispi 2009
Cruz-Lemini 2012, TRUFFLE 2015
FETAL GROWTH RESTRICTION
stages of fetal deterioration and latency time until (imminent) fetal death
PLACENTAL DISEASE
Doppler changes progressively
cCTG, BPP and CTG are [yes/no] measures and change late or very late
LATENCY TIME TO
DETERIORATION/
DEATH
28d
HYPOXIA
21d
SUSPICION
ACIDOSIS
10d
LIKELY ACIDOSIS
4-7d
BPP <6
1-2d Hours
IMMINENT DEATH
Stage I II III IV
Measures
Dopplers
UA
DV
CTG

UA REDV
DVPI >p95
I Placental insufficiency
II Severe placental
insufficiency
III Low suspicion of
acidosis
IV High suspicion of
acidosis
AEDV
DV AREDV
CPR
<p5
Ut A
>p95
EFW
<p3
Classification of FGR in stages of severity/deterioration

Integrated
Management of IUGR
EFW < p10
I
II
III
IV
1. Identify small fetus
CPR, UtA, EFW<p3
SGA FGR
2. Distinguish
SGA vs FGR (stages)
3. Timing delivery
and follow up

2. Distinguish FGR vs SGA

Integrated
Management of IUGR
EFW < p10
3. Timing delivery
and follow up I
II
III
IV
37w (/w)
34w (/2-3d)
30w (/d)
Any time
39 w (/2w)
CPR, UtA, EFW<p3 (+sFflt1/PlGF)
SGA FGR
2. Distinguish
SGA vs FGR

Late-onset
Early-onset
The “small fetus”: main clinical scenarios
Placental insufficiency
“Second
trimester” FGR
30% 90% 60%

LATE-ONSET FGR
EARLY-ONSET FGR
FGR: 1 PROTOCOL, 2 CLINICAL SCENARIOS
CONSIDERATIONS FOR DELIVERY

FGR is a single entity
With 2 clinical scenarios: early and late-onset
Late-mild
No IUFD <37w (risk at term)
PROBLEM: DETECTION
Q: Is it FGR or SGA?

Integrated
Management of IUGR
EFW < p10
3. Timing delivery
and follow up I 37w (/w)
II 34w (/2-3d)
III 30w (/d)
IV Any time
39 w (/2w)
SGA FGR
2. Distinguish
SGA vs FGR
*Most late-onset FGR are
(and remain at) stage I.
If other stages deliver
according to protocol

(LATE) SMALL FETUS: CLINICAL MANAGEMENT BY RISK
Define risk and management according to size and Doppler
FGR
Placental insufficiency
POORER OUTCOMES
very small (<p3) or abnormal Dopplers
SGA
Unknown (constitutional + others)
NORMAL OUTCOMES
p4-9 and normal Dopplers
Planned delivery 39+w
Follow every 2 weeks
Planned delivery 37+w
Follow every week

Early-severe
High risk IUFD preterm
PROBLEM: TIMING DELIVERY
Q: Delivery? Next exam?

cardiac ischemia
Diastolic failure
Systolic cardiac
failure
Centralization
Increment placental
impedance
(early-onset) FGR: timing of delivery and next evaluation
WHAT IS THE DEGREE OF FETAL DETERIORATION?
Clinical
Decision:
balance
how sick is the
fetus
(how long
before
deterioration/d
eath)
how risky is to
deliver?
DIFFERENCE
FGR VS SGA
WHAT ARE THE RISKS OF PREMATURITY?
VERY HIGH
MODERATE HIGH
MINIMAL MILD
Prognostic/Acute markers
INDICATION ABOUT THE SHORT-TERM RISK
OF IUFD/BRAIN INJURY
BPP < 6
cCTG: reduced STV
CGTdec
(NO PLACENTAL DISEASE)

FGR staging system
Follow-up and timing of delivery according to the stage of fetal deterioration
Stage I II III IV
Deliver 37 34 30 Any time
Exam intervals 7 days 2-3 days Daily Daily or more frequent
28d 21d 10d 4-7d 1-2d Hours
Measures
Dopplers
UA
DV
CTG

BPP <6
(Optional)
FGR staging system
Follow-up and timing of delivery according to the stage of fetal deterioration
Stage I II III IV
IF NO EXPERTISE WITH DV USE ONLY UA DOPPLER AND CTG
28d 21d 10d 4-7d 1-2d Hours
Measures
Dopplers
UA
CTG
“SIMPLIFIED” VERSION

Early-severe
Late-mild
PROBLEM: DETECTION

Early-severe
Early and late onset FGR = different clinical scenarios and needs
HOWEVER, NO NEED FOR DIFFERENT PROTOCOLS
Late-mild
PROBLEM: DETECTION
(Most cases are) Stage II to IV (Most cases are) Stage I

Integrated
Management of IUGR
EFW < p10
3. Timing delivery
and follow up
I 37w (/w)
II 34w (/2-3d)
III 30w (/d)
IV Any time
39 w (/2w)
SGA FGR
2. Distinguish
SGA vs FGR
https://portal.medicinafetalbarcelona.org/calc/
(most) late-onset FGR
(most) early-onset FGR

www.medicinafetalbarcelona.org/
1
IDENTIFY
SGA
2+3
CLASSIFY
SGA vs FGR
and STAGE
30w 34w 37w
24-29w 39-40w
deliver no later than:
IV: deliver
II : follow up /2-3 days
I : follow up 1/week
III: follow up daily
SGA: follow up every 2 weeks
FGR stage-based management
Follow-up and delivery according to fetal deterioration

Integrated
Management of IUGR
EFW < p10
3. Timing delivery
II 34w (/2-3d)
III 30w (/d)
IV Any time
39 w (/2w)
CPR, UtA, EFW<p3
SGA FGR
2. Distinguish
SGA vs FGR
sFflt1/PlGF
>38 independent
criterion
correlates
with (late)
stages
>655 risk
deterioration
but
Essentially
predicts or
identifies PE
Huge
overlap in
isolated
FGR
ANGIOGENIC FACTORS AND FGR

FGR staging system
Mode of delivery
Stage I II III IV
Cesarean Section
Vaginal or Cesarean Section
(according to Bishop and CPR,
mechanical methods)

FGR stage I and induction of labor
Predictors of cesarean section for fetal distress (NRFS)
Oros 2015
BISHOP AND CPR
Bishop<2
AND
CPR<5
Bishop<2
OR
CPR<5
Bishop>=2
AND
CPR>=5
Risk of CS for fetal
distress
40% 20% 10%
METHOD CERVICAL
RIPENING
DINOPROSTONE FOLEY BALLOON
Risk of CS for fetal
distress
25% 10%
Villalain 2019,
DiMascio 2021

CONCLUSIONS

Stillbirth: 3%
No stillbirths
Main message: have a protocol (adapted to your setting)
BOTH IN EARLY AND IN LATE FGR A PROTOCOL-BASED MANAGEMENT ACHIEVES
OPTIMAL OUTCOMES IN COMPARISON WITH HISTORICAL SERIES

Integrated
Management of IUGR
EFW < p10
3. Timing delivery
II 34w (/2-3d)
III 30w (/d)
IV Any time
39 w (/2w)
CPR, UtA, EFW<p3 (+ sFflt1/PlGF>38)
SGA FGR
2. Distinguish
SGA vs FGR

Google search:
fetal medicine barcelona calculators

1. Identify the “small fetus”
2. Classify SGA vs FGR (& severity)
3. Decide follow-up + timing delivery
Integrated Management of FGR

FMFbarcelona2024 - Eduard Gratacós - MANAGEMENT OF FETAL GROWTH RESTRICTION.pdf

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