Restriccion del crecimiento Fetal: Manejo basado en estadios

Dr. Jorge Avalos
Restricción de
crecimiento Fetal
•manejo
•consecuencias en la
programación fetal

medicina
materno
fetal
HNDAC
Lagercrantz
1997 - The Lancet
“Better born too soon than too small”

medicina
materno
fetal
HNDAC
Antenatal identiﬁcation of SGA and outcome
**
**
*
*
Normal
group
20th
percentile
10th
percentile
Moderate
SGA
Severe
SGA
Extreme
SGA
32
16
8
4
2
1
Grade of weight deviation
Riskofseriousfetalcomplication(oddsratio±95%Cl)
§ §§
Power esti
We assum
among SG
signiﬁcanc
pregnancie
halved inc
with antep
RESULT
The numb
among tho
Compared
four-fold i
serious feta
suffered ad
were at an
death (eith
AGA fetus
and extrem
(95% CI, 4
OR: 4.1; 95% CI, 2.5–6.8

medicina
materno
fetal
HNDAC
Adaptacion fetal a la insuficiencia placentaria
rogramación fetal!
ales y papel de la “nutrición” fetal!
!
Eduard Gratacos!
Medicina Maternofetal i Neonatologia de Barcelona!
de Déu i Hospital Clínic, Universitat de Barcelona!
ww.medicinafetalbarcelona.org

Gestación de 14 sem
www.medicinafetalbarcelona.org/
Normal and
abnormal
placental
implantation
medicina
materno
fetal
HNDAC
Programación fetal!
es y papel de la “nutrición” fetal!
!uard Gratacos!
Maternofetal i Neonatologia de B
ospital Clínic, Universitat d
afetalbarcelona.org
resistencia
placentariaarteria umbilical arteria uterina
<30% de función

Normal and
abnormal
placental
implantation
medicina
materno
fetal
HNDAC
!uard Gratacos!
afetalbarcelona.org
resistencia
placentariaarteria umbilical
<30% de función
disminución flujo vena umbilical
crecimiento
fetal
restringido

!uard Gratacos!
afetalbarcelona.org
Normal and
abnormal
placental
implantation
medicina
materno
fetal
HNDAC
resistencia
placentaria
arteria umbilical
disminución flujo vena umbilical
crecimiento
fetal
restringido
redistribucion de ﬂujo
arteria cerebral media
arteria umbilical
ICP

!
Eduard Gratacos!
na Maternofetal i Neonatologia de Barcelon
Hospital Clínic, Universitat de Barce
inafetalbarcelona.org
Normal and
abnormal
placental
implantation
medicina
materno
fetal
HNDAC
resistencia
placentaria
arteria umbilical
disminución flujo vena umbilicalremodelacion cardiaca
sistole
diastole

!
Eduard Gratacos!
na Maternofetal i Neonatologia de Barcelon
Hospital Clínic, Universitat de Barce
inafetalbarcelona.org
Normal and
abnormal
placental
implantation
medicina
materno
fetal
HNDAC
resistencia
placentaria
arteria umbilical
disminución flujo vena umbilicaldisfuncion cardiaca
sistole
diastoleHTA fetal
disfuncion diastolica
Doppler pre-cordial

medicina
materno
fetal
HNDAC
Manejo enfocado en estadios y severidad
rogramación fetal!
!
Eduard Gratacos!
Medicina Maternofetal i Neonatologia de Barcelona!
de Déu i Hospital Clínic, Universitat de Barcelona!
ww.medicinafetalbarcelona.org

Secuencia de deterioro fetal
Enfermedad placentaria
> impedancia
Hipoxia
Centralización
Hipoxia avanzada
Acidosis
Injuria severa
Muerte fetal
Marcadores crónicos Marcadores agudos
IP AUt >p95
ICP<p5
IP AU>p95
IP ACM<p5 IP IAo >p95
DV >p95
cCTG <3ms
PBF <4
CTG dips
DV DRv
AU DAu AU DRv
ción de 14 sem
tal ratio is more
UA or MCA alone
CPR
<p5
0
=
IVIIIIII
cCTG%STV<3*ms
Pathological'
CGT
www.fetalmedicinebarcelona.org/
Fetal I+D Protocol early-onset IUGR
Sequence Doppler (and CTG) changes
CPR
<p5
Ut A
>p95
MCA
<p5
DV
(a rev)
CGT decelerations of
reduced short-term
variability
REDVDV >p95 UVpuls
r normal but EFW<p3
Increased resistance
Initial redistribution
increased resistance
and/or redistribution
modynamic alteration
V High risk of death
AEDV AoI >p95

> impedancia
Hipoxia
Centralización
Hipoxia avanzada
Acidosis
Injuria severa
Muerte fetal
IP AUt >p95
ICP<p5
IP AU>p95
DV >p95
cCTG <3ms
PBF <4
CTG dips
DV DRv
AU DAu AU DRv
ción de 14 sem
tal ratio is more
UA or MCA alone
CPR
<p5
0
=
IVIIIIII
cCTG%STV<3*ms
Pathological'
CGT
CPR
<p5
Ut A
>p95
MCA
<p5
DV
(a rev)
reduced short-term
variability
REDVDV >p95 UVpuls
r normal but EFW<p3
AEDV AoI >p95

> impedancia
Hipoxia
Centralización
Hipoxia avanzada
Acidosis
Injuria severa
Muerte fetal
IP AUt >p95
ICP<p5
IP AU>p95
DV >p95
cCTG <3ms
PBF <4
CTG dips
DV DRv
AU DAu AU DRv
ción de 14 sem
tal ratio is more
UA or MCA alone
CPR
<p5
0
=
IVIIIIII
cCTG%STV<3*ms
Pathological'
CGT
CPR
<p5
Ut A
>p95
MCA
<p5
DV
(a rev)
reduced short-term
variability
REDVDV >p95 UVpuls
r normal but EFW<p3
AEDV AoI >p95
LEVE ALTOMEDIO
RIESGO DE PREMATURIDAD

Prematuridad
Intra-utero
•Mortalidad
•Daño neurologico
•Madurez fetal
•Ingreso a UCIN

ogramación fetal!
y papel de la “nutrición” fetal!
!
d Gratacos!
ernofetal i Neonatologia de Barcelon
al Clínic, Universitat de Barce
barcelona.org
RCIU
mortalidad
daño neurologico
madurez fetal
ingreso UCI-NPrematuridad
daño por
insuﬁciencia
placentaria
Edad gestacional

Evidencias actuales y papel de la “nutrición” fetal!
!
Eduard Gratacos!
BCNatal – Centre de Medicina Maternofetal i Neonatologia de Barcelona!
Hospital Sant Joan de Déu i Hospital Clínic, Universitat de Barcelona!
www.medicinafetalbarcelona.org
RCIU
mortalidad
daño neurologico
madurez fetal
daño por
insuﬁciencia
placentaria
Edad gestacional

ramación fetal!
papel de la “nutrición” fetal!
!
Gratacos!
ofetal i Neonatologia de Barcelona!
Clínic, Universitat de Barcelona!
rcelona.org
RCIU
*TRUFFLE 2013
Edad gestacional
26ss 28ss
2%
por cada dia
mortalidad
>90% <10%*20 - 40%*
Bashat 2007
30%*superviviencia intacta >50%

Bashat 2007
Fig. 1. Neonatal survival and in-
tact survival rates per gestational
week. This figure shows the in-
crease in survival (black dia-
monds) and intact survival rates
until discharge (black bars) in
growth-restricted neonates with
advancing gestational week.
Baschat. Neonatal Outcome in
Fetal Growth Restriction. Obstet
Gynecol 2007.
analysis, neither center of origin nor country of origin
influenced the relationship between gestational age,
birth weight, and Doppler parameters and neonatal
morbidity (Nagelkerke r2
ϭ0.05, Pϭ.796), neonatal
death (Nagelkerke r2
ϭ0.09, Pϭ.534) and intact sur-
vival (Nagelkerke r2
ϭ0.06, Pϭ.206).
DISCUSSION
Fetal growth restriction is a prominent contributor to
perinatal mortality and morbidities extending all the
1–3,17
intera
tion t
The a
identi
anatom
sonog
Fetal
tion a
with a
Using
<26 26-28
DVa'(rev)
Yes No
IUFD
P
Cochr
Bas
mortalidad
DV : ausente o reverso: buena correlación con academia
mortalidad perinatal : 40 -100%
Hecher 1995-2003
Schwarze 2005

cCTG6STV<3'ms
BPP
variabilidad a corto plazo
STV <3ms
marcador agudo de muerte fetal
Hecher 2001

ramación fetal!
!
Gratacos!
rcelona.org
RCIU
*TRUFFLE 2013
Edad gestacional
26ss 28ss
2%
por cada dia
mortalidad
>90% <10%*20 - 40%*
Bashat 2007
30%*superviviencia intacta >50%
Solo indicación
materna
DVa'(rev)
CGT
cCTG6STV<3'ms
Pathological'
CGT
DV ar STV<3ms

0
15
30
45
60
(%)
Controls
IUGR antegrade AoI
IUGR retrograde AoI
Controls
IUGR DV<5 z-score
IUGR DV>5 z-score
*
*
Brain US anomalies in 30w IUGR
ramación fetal!
!
Gratacos!
rcelona.org
RCIU
Edad gestacional
28ss 32ss
>90% <10%*30 - 40%*
daño neurologico
AUdr después de las 30s los
riesgos de obito superan
a los de la prematuridad
Fouron’2004
Del'Rio'2008
Cruz Martinez'2012

ramación fetal!
!
Gratacos!
rcelona.org
RCIU
Edad gestacional
28ss 32ss
>90% <10%*30 - 40%
daño neurologico
15
30
45
60
(%)
Controls
IUGR antegrade AoI
IUGR retrograde AoI
Controls
IUGR DV<5 z-score
IUGR DV>5 z-score
*
*

ramación fetal!
!
Gratacos!
rcelona.org
RCIU
Sotiriadis - Bashat ACOG junio 2015
Edad gestacional
32ss 34ss
corticoterapia
madurez fetal
el neurodesarrollo mejora con la administración de corticoides
Paralisis Cerebral Disfuncion severa

AU diastole ausente
precede el deterioro fetal
en 1 semana
Ferrazi 2002
Doppler sequence in IUGR Ferrazzi et al.
are reported. Continuous variables were tested for normality
(Shapiro-Wilks test) and then analyzed with Student’s t-test.
Categorical variables were analyzed with Fisher’s exact test.
P < 0.05 was considered significant. The duration of inten-
sive fetal monitoring from admission in the fetal intensive
care unit to delivery was expressed as number of days prior
to delivery. In each patient, we calculated the number of days
prior to delivery when a persistently abnormal velocimetric
measurement (i.e. for two consecutive examinations) was
identified for the first time.
Longitudinal cumulative onset time curves were calculated
for each Doppler measurement to describe the proportion
of cases with abnormal Doppler measurements during the
observation time. To allow for a statistical analysis, umbilical
changes from absent to reverse end-diastolic flow (AEDF to
REDF) and ductus venosus changes from abnormal wave-
form (DV S/a) to reverse a-wave (DV RF) were considered
independently, as two different marks of adaptation of pro-
gressive severity. Linear regression analysis was used to
approximate this biological phenomenon described by the
longitudinal cumulative curves. The α-coefficient and the
intercept value were calculated and anova and Student’s
t-test were carried out to test the differences between the dif-
ferent curves. Univariate logistic regression was used to iden-
tify which one of the independent variables (fetal weight,
gestational age at birth or Doppler changes) was a significant
predictor of the dependent variable (perinatal outcome).
Additionally, in a subset of nine cases that entered the study
with Doppler abnormalities in the UA and middle cerebral
artery (MCA) (‘early’ changes), the average incidence rate of
subsequent abnormal Doppler findings in other vessels was
0
10
20
30
40
50
60
70
80
90
100
–16 –14 –12 –10 –8 –6 –4 –2 0
Days prior to delivery
AbnormalDopplerfindings(%)
262521191411975
Observed fetuses (n)
Figure 1 Cumulative onset time curves of Doppler abnormalities for
each fetal vessel examined. Time ‘0’ refers to the date of delivery. ᭺,
MCA PI; ᮀ, UA AEDF; ᭝, DV S/a; ᭿, UA RF; , PA PV; ᭡, DV RF;
, AO PV. Abbreviations are given in Table 1.
Table 2 Statistical analysis between α-coefficient/intercept ratios of
cumulative curves
t d.f. P*
MCA — UA AEDF 18 24 < 0.0001
UA AEDF — DV S/a 12 24 < 0.0001
DV S/a — PA 5.3 24 < 0.0001
PA — UA RF 2.2 24 < 0.03
UA RF — DV RF 1.0 24 NS
DV RF — AO 0.04 24 NS
30
45
60
(%)
Controls
IUGR antegrade AoI
IUGR retrograde AoI
Controls
IUGR DV<5 z-score
IUGR DV>5 z-score
*
*
Pathological'
CGT
precede en 1 semana a la alteracion del DV
Cruz-Martinez 2011
Figueras 2009

ramación fetal!
!
Gratacos!
rcelona.org
RCIU
Edad gestacional
32ss 34ss
corticoterapia
madurez fetal
30
45
60
(%)
Controls
IUGR antegrade AoI
IUGR retrograde AoI
Controls
IUGR DV<5 z-score
IUGR DV>5 z-score
*
*

Evidencias actuales y papel de la “nutrición” fetal!
!
Eduard Gratacos!
BCNatal – Centre de Medicina Maternofetal i Neonatologia de Barcelona!
Hospital Sant Joan de Déu i Hospital Clínic, Universitat de Barcelona!
mortalidad
daño neurologico
madurez fetal
daño por
insuﬁciencia
placentaria
Edad gestacional

ramación fetal!
!
Gratacos!
rcelona.org
RCIU
DIGITAT 2011
Edad gestacional
34ss 37-38ss
Ingreso UCI-N
ausencia de descompensacion fetal
650 SGA >37 weeks
Induction
GA at delivery 38w
(96% indution)
Fetal distress
18%
Acidosis
12%
NICU
admission
3%
Expectant
management
GA at delivery 39.4w
(50% induction)
Fetal distress
20%
Acidosis
13%
NICU
admission
4%
Induction versus expectant monitoring for intrauterine growth restriction at term:
randomised equivalence trial (DIGITAT). BMJ 2011

ramación fetal!
!
Gratacos!
rcelona.org
RCIU
(NEURO)DEVELOMENTAL DIGITAT 2011
Edad gestacional
34ss 37-38ss
Ingreso UCI-N
ausencia de descompensacion fetal
292 24-months SGA >37 weeks
Induction
GA at delivery 38w
Abnormal
neurodevelopment*
25%
Abnormal
neurobehavior
14%
Expectant
management
GA at delivery 39.4w
Abnormal
neurodevelopment
29%
Abnormal
neurobehavior
11%
Effects on (neuro)developmental and behavioral outcome at 2 years of age of induced
labor compared with expectant management in intrauterine growth-restricted infants:
long-term outcomes of the DIGITAT trial. AJOG 2012
Severe
IUGR
Admission
Neonatal
Unit

ramación fetal!
!
Gratacos!
rcelona.org
RCIU
Edad gestacional
34ss 37-38ss
Ingreso UCI-N
ausencia de descompensacion fetal Termino electivo
Late-onset
IUGR
c
Constitutional
SGA
* (UtA)1st visit +UA+MCA
Late-onset
IUGR
c
Constitutional
SGA
1st visit
Late-onset
IUGR
c
Constitutional
SGA
** (UtA)1st visit +UA+MCA+DV

ramación fetal!
!
Gratacos!
rcelona.org
RCIU
Edad gestacional
34ss 37ss
Manejo basado en estadios
www.medicinafetalbarcelona.org/docencia
Late-onset
IUGR
c
Late-onsetIUGR:follow-up
Dopp
Dopp
Dopp
Dopp
Constitutional
SGA
* (UtA)1stvisit+UA+MCA
**(UtA)1stvisit+UA+MCA+DVwww.medicinafetalbarcelona.org/docencia
Late-onset
IUGR
c
Late-onsetIUGR: follow-up
Dopp
Dopp
Dopp
Dopp
Constitutional
SGA
www.medicinafetalbarcelona.org/docencia
Late-onset
IUGR
c
Late-onset IUGR: follow-up
Dopp
Dopp
Dopp
Dopp
Constitutional
SGA
30ss26ss 28ss
(rev)
cal'
IUFD 23% in BP
Poor correl
Cochrane: poor cVa'(rev)
cCTG6STV<3'ms
ogical'
T
BPP
IUFD 23% in BPP=6 and 11% in BPP=8
Poor correlation with DVa(rev)
Cochrane: poor contribution to prediction<29 29-32 >32.0
0
15
30
45
60
(%)
Controls
IUGR antegrade AoI
IUGR retrograde AoI
Controls
IUGR DV<5 z-score
IUGR DV>5 z-score
*
*
0
15
30
45
60
(%)
Controls
IUGR antegrade AoI
IUGR retrograde AoI
Controls
IUGR DV<
IUGR DV>
*
Brain US anomalies in 30w
marcadores agudos: muerte fetal / daño neurológico diagnostico
Alta sospecha acidemia baja sospecha acidemia Insf. placentaria sev. Inf. plac. leve
Parto por cesarea induccion
diario 1-2 dias 2v semanal semanal
IIIIIIIV

medicina
materno
fetal
HNDAC
ogramación fetal!
s y papel de la “nutrición” fetal!
!rd Gratacos!
ternofetal i Neonatologia de Ba
pital Clínic, Universitat de
talbarcelona.org
RCIU: consecuencias en la programación fetal

medicina
materno
fetal
HNDAC
ctuales y papel de la “nutrición” fetal!
!
Eduard Gratacos!
Medicina Maternofetal i Neonatologia de
e Déu i Hospital Clínic, Universitat
medicinafetalbarcelona.or
Reorganizacion cerebral
Remodelacion cardiovascular

medicina
materno
fetal
HNDAC
Remodelacion cardiovascular1986 Barker (MRC Unit, Southampton, UK):!
Coronary heart disease mortality rates

medicina
materno
fetal
HNDAC
Redistribuir FlujoRCIU
cambios adaptativos cambios epigeneticos
Programacion
cardiaca
alteracion
doppler

medicina
materno
fetal
HNDAC
RCIU
postnatal persistance
of cardiovascular
remodeling
fetal cardiac
dysfunction
cardiovascular
disease in adultho
INTRAUTERINE
GROWTH
RESTRICTION hypertension
coronary diseas
stroke!
obesity!
diabetes
disfuncion cardiaca
remodelacion
cardiaca
persiste infancia
Enfermedad cardiaca
en el adulto
HTA
enfermedad coronaria
obesidad
ACV
diabetes

medicina
materno
fetal
HNDAC
RCIU
Skilton&Lancet&2007,&Crispi&Circula6on&2010,&Crispi&AJOG&2012
Cardiovascular,
remodeling
control IUGR
TA)90/65
cIMT = 0.386 mm
TA)115/80
cIMT = 0.434 mm
postnatal cardiovascular remodelling
globular)heart!↓longitudinal)mo;on!↓stroke)volume!↑heart)rate!=)cardiac)output
hypertension!preCarteriosclerosis
IMPACT,OF,LATE,
IUGR/SGA
near)term)SGA)fetuses)
without)signs)of)poor)
prognosis)also)
presented)CV)
remodeling)
Skilton&Lancet&2007,&Crispi&Circula6on&2010,&Crispi&AJOG&2012
Cardiovascular,
remodeling
control IUGR
TA)90/65
cIMT = 0.386 mm
TA)115/80
cIMT = 0.434 mm
IMPACT,OF,LATE,
IUGR/SGA
prognosis)also)
presented)CV)
remodeling)
control ART
ValenzuelaIAlcaraz&Circula6o
decreased)systolic)mo;on impaired)relaxa;on
8
7
6
4
3
0
Rightlongitudinalsystolicmotion!Annularpeakvelocity(S’,cm/s)!Displacement(TAPSE,mm)
*
5
1
2
right S’
*
TAPSE
80
70
60
40
30
0
Diastolicfunction!Leftisolumetricrelaxationtime(IRT,ms)!RightEdelecelerationtime(Edec,ms)
*
50
10
20
E dec
*
IRT
Data)are)median+SEM.)*P<0.05)adjusted)by)GA,)birthweight)cen;le)and)preeclampsia)
CONTROL
ART
Remodelacion Cardiovascular Posnatal
Control corazon globular hipertroﬁa
menor movimiento
menor volumen eyección
incremento FC
control ART
Valenzu
decreased)systolic)mo;on impaired)relaxa;on
8
7
6
4
3
0
Rightlongitudinalsystolicmotion!Annularpeakvelocity(S’,cm/s)!Displacement(TAPSE,mm)
*
5
1
2
right S’
*
TAPSE
80
70
60
40
30
0
Diastolicfunction!Leftisolumetricrelaxationtime(IRT,ms)!RightEdelecelerationtime(Edec,ms)
*
50
10
20
E dec
*
IRT
Data)are)median+SEM.)*P<0.05)adjusted)by)GA,)birthweight)cen;le)and)preeclampsia)
Cardiovascular,
remodeling
control IUGR
TA)90/65
cIMT = 0.386 mm
TA)115/80
cIMT = 0.434 mm
IMPACT,OF,LATE,
IUGR/SGA
prognosis)also)
presented)CV)
remodeling)
Cardiovascular,
remodeling
control IUGR
TA)90/65
cIMT = 0.386 mm
TA)115/80
cIMT = 0.434 mm
IMPACT,OF,LATE,
IUGR/SGA
prognosis)also)
presented)CV)
remodeling)
Hipertension
pre-ateroesclerosis

medicina
materno
fetal
HNDAC
RCIU
of cardiovascular
remodeling
fetal cardiac
dysfunction
cardiovascular
disease in adultho
INTRAUTERINE
GROWTH
RESTRICTION hypertension
coronary diseas
stroke!
obesity!
diabetes
Predecir?????
Prediccion
Prevencion
Personalizada
Participatoria
4P medicina

medicina
materno
fetal
HNDAC
RCIU
of cardiovascular
remodeling
Barker&BMJ&1986,&Barker&BMJ&1995&,&Hecher&Circula6on&1995,&Crispi&AJOG
fetal cardiac
dysfunction
INTRAUTERINE
GROWTH
RESTRICTIONPredecir?????
Score
Cardiovascular
Cruz-Lemini 2014

medicina
materno
fetal
HNDAC
A fetal cardiovascular score to predict infant hypertension and arterial remodeling in
intrauterine growth restriction
Cruz-Lemini, Crispi, Gratacos
AJOG 2014
among the different parameters, a hypertension and arterial remodeling in ters continued
predictive valu
diovascular en
ratio (OR, 2.2
.001), right sp
95% CI, 1.4e
IVRT (OR, 2.2
.001) had the
composite scor
best perinatal
graphic predict
combination o
regression anal
cular score was
score), cerebro
right sphericity
IVRT (z-score
the following e
1:907 þ ðTAP
þ ðcerebropl
þ ðright sphe
þ ðIVRT Â
The equatio
tivity, 77% s
predictive value
value, 3.9 posi
0.1 negative li
those IUGR ca
sion and arter
operating char
son was perfor
FIGURE 1
Univariate analysis for the association between perinatal and fetal
echocardiographic parameters with hypertension and arterial
remodeling in IUGR infants
Hypertension and arterial remodeling were deﬁned as mean blood pressure of >95th percentile and
aortic intima media of >75th percentile at 6 months of age. Fetal parameters included as z-scores

medicina
materno
fetal
HNDAC
intrauterine growth restriction
Cruz-Lemini, Crispi, Gratacos
AJOG 2014
FIGURE 2
Components of the fetal cardiovascular score for the prediction of
hypertension and arterial remodeling
Obstetrics Research
GURE 2
omponents of the fetal cardiovascular score for the prediction of
ypertension and arterial remodeling
Obstetrics Researchperformance than perinatal factors and
fetoplacental Doppler scans that were
used for establishing the severity of the
IUGR.
Echocardiographic measurements in
fetuses were consistent with previous
studies that demonstrated significant
differences in cardiac function under
IUGR.1-3,5,11,12,32,37-40
Likewise, in-
creased blood pressure and aIMT pre-
viously had been reported in IUGR
neonates and children.3,32,38,40-42
The
present study expands previous findings.
Longitudinal follow-up evaluations dem-
onstrated the relationship between pre-
natal echocardiography and postnatal
cardiovascular findings.
As expected, gestational age and
birthweight percentile showed no associ-
ationwith the occurrence of hypertension
IVRT, isovolumic relaxation time; TAPSE, tricuspid annular-plane systolic excursion.
Cruz-Lemini. Fetal echocardiography to predict postnatal hypertension in IUGR. Am J Obs
an perinatal factors and
oppler scans that were
hing the severity of the
aphic measurements in
onsistent with previous
emonstrated significant
cardiac function under
2,37-40
Likewise, in-
ressure and aIMT pre-
en reported in IUGR
children.3,32,38,40-42
The
pands previous findings.
ow-up evaluations dem-
lationship between pre-
ography and postnatal
ndings.
gestational age and
entile showed no associ-
IVRT, isovolumic relaxation time; TAPSE, tricuspid annular-plane systolic excursion.
Cruz-Lemini. Fetal echocardiography to predict postnatal hypertension in IUGR. Am J Obstet Gynecol 2014.
indice esfericidad ICP TAPSE TRI

medicina
materno
fetal
HNDAC
intrauterine growth restriction Cruz-Lemini, Crispi, Gratacos
AJOG 2014
trial in a l
that the in
with arter
can be pre
suppleme
life.49
Among
the longi
and func
ings from
allowed u
effects of
controllin
much as p
by includ
IUGR, ex
because o
all the s
suspected
FIGURE 3
Receiver operating characteristic curves illustrating the predictive value
of fetal CV score

medicina
materno
fetal
HNDAC
RCIU
of cardiovascular
remodeling
fetal cardiac
dysfunction
cardiovascul
disease in adult
INTRAUTERINE
GROWTH
RESTRICTION hypertensio
coronary dise
stroke!
obesity!
diabetes
S:90 - E: 85%
Score
Cardiovascular
Remodelamiento
vascular
Intervención
Estilo de vida
Dieta: omega 3
ejercicio
hipotensores
Williams 2009
Kavey 2006
Skilton 2012-2013

medicina
materno
fetal
HNDAC
ncias actuales y papel de la “nutrición” fetal!
!
Eduard Gratacos!
Centre de Medicina Maternofetal i Neonatologia de Barcelona!
ant Joan de Déu i Hospital Clínic, Universitat de Barcelona!
exposure
Fetal&programming&
Brain&reorganiza0on&
exposure
Injuria

medicina
materno
fetal
HNDAC
ncias actuales y papel de la “nutrición” fetal!
!
Eduard Gratacos!
Centre de Medicina Maternofetal i Neonatologia de Barcelona!
ant Joan de Déu i Hospital Clínic, Universitat de Barcelona!
Normal
acoustic
signature
re
Ultrasound texture analysis
Normal
acoustic
signature
re Ultrasound texture analysis
Cual es normal?

medicina
materno
fetal
HNDAC
videncias actuales y papel de la “nut
!
Eduard Gratac
Natal – Centre de Medicina Maternof
spital Sant Joan de Déu i Hosp
www.med
NEW THERAPIES
NEW IMAGING
IMPROVING NEURODEVELOPMENTAL
DISORDERS OF FETAL ORIGIN
NOVEL RESEARCH LINES
IMPROVING DETECTION NEW THERAPIES
DISORDERS OF FETAL ORIGIN
MPROVING DETECTION
NEW THERAPIES
NEW IMAGING
BIOMARKERS
MPROVING DETECTION
Mejorar Diagnostico
Nuevos Biomarcadores
nuevas terapias
Mejorando el estudio de los origenes fetales
del neurodesarrollo

medicina
materno
fetal
HNDAC
videncias actuales y papel de la “nu
!
Eduard Grata
Natal – Centre de Medicina Materno
spital Sant Joan de Déu i Hos
www.me
Microestructura
CONECTIVIDAD
Desarrollo cortical
Efectos de la desnutrición
Fetal en el neurodesarrollo
MICROSTRUCTURE
METABOLISM
CONNECTIVITY
CORTICAL
DEVELOPMENT
MICROSTRUCTURE
METABOLISM
CORTICAL
DEVELOPMENT
MICROSTRUCTURE
METABOLISM
CONNECTIVITY
CORTICAL
DEVELOPMENT

medicina
materno
fetal
HNDAC
Microestructura
Analisis de Textura
MICROSTRUCTURE
METABOLISM
CONNECTIVITY
CORTICAL
DEVELOPMENT
TEXTURE ANALYSIS
Sanz et al. Fet Diagn Ther 2013.
FETAL MRI
SGAs vs AGA
LATE IUGR
TEXTURE ANALYSIS
Sanz et al. Fet Diagn Ther 2013.
FETAL MRI
Texture analysis showed brain differences in SGA fetuses that increase
VD SGAsSGAs vs AGA
LATE IUGR
J Ultrasound Med 2011
Fetal Diagn Ther 2012
Am J Obstet Gynecol 2012

Medicina Fetal Barcelona 2015
medicina
materno
fetal
HNDAC
videncias actuales y papel de la “n
!
Eduard Grat
Natal – Centre de Medicina Mater
spital Sant Joan de Déu i H
www.m
Infantes con RCIU muestran
disminucion de la conectividad
normal RCIU

Medicina Fetal Barcelona 2012
medicina
materno
fetal
HNDAC
Fetus Young OldChild Mature
IMPACT OF
ENVIRONMENT
BIOLOGIC-PROGRAMMING-AND-AGE
OPPORTUNITY FOR
CORRECTION

medicina
materno
fetal
HNDAC
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Restriccion del crecimiento Fetal: Manejo basado en estadios

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Restriccion del crecimiento Fetal: Manejo basado en estadios