Intrauterin tillväxthämning

Transkript

1 Intrauterin tillväxthämning

2 Intrauterin tillväxthämning IUGR = Intrauterine growth restriction vs. SGA = small for gestational age

3 Biparietal diameter (BPD) Femurlängd (FL) FL Bukdiameter (AD) AD

4 Fetal weight (g) LGA fetus AGA fetus SGA fetus SGA fetus Gestational age (weeks)

5 Fetal weight (g) SGA Gestational age (weeks)

6 Fetal weight (g) IUGR + SGA Gestational age (weeks)

7 Fetal weight (g) IUGR AG A SGA IUGR Gestational age (weeks)

8 Intrauterin tillväxthämning Maternella risk faktorer/orsaker - essentiell eller graviditetshypertoni - preeklampsi - kronisk njursjukdom - kronisk hjärt- el. lungsjukdom - diabetes mellitus - autoimmuna sjukdomar (SLE) - undernäring - rökning, alkohol, narkotika

9 Intrauterin tillväxthämning Fetala faktorer - kromosomala avvikelser (trisomi 13, 18) - kongenitala malformationer - infektioner cytomegalovirus toxoplasmos malaria

10 Placentation Trophoblastic cell columns (CT) at fetal maternal boundary Intervillous space Extravillous interstitial trophoblast (T) destroy arterial media, replace it by fibrinoid material (F) Endovascular trophoblast cells (E) move down the arteries retrogradely as far as the inner myometrium, and replace endothelial cells Placental-bed giant cells (GC)

11 Placentation Intervillous space Extent and depth of trophoblast invasion is less in pathological compared with normal pregnancy reduced blood flow to feto-placental unit poor fetal growth ischaemic placenta can trigger systemic endothelial dysfunction in mother and onset of preeclampsia Non-pregnant Pre-eclampsia/IUGR Normal pregnancy

12 Incidence of preeclampsia Para 0 6% Para 1+ 3% 2nd pregnancy: 12% if 1st pregnancy affected 0,7% if 1st pregnancy not affected Change of partner returns risk to that of para 0

13 SGA 3 rd centile Ødegard R et al. Obstet Gynecol 2000 Preeclampsia Controls % 95% CI % Overall 12 3 Mild Moderate Severe Late PE (> 32 wks) Early PE (< 32 wks)

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15 Uterine artery Doppler

16 Doppler ultralyd - uterin artärene Diastolisk notch och hög PI Före veckor - Fysiologisk (15%) Efter 24 veckor - Indikerar utveckling av Preeklampsi Hypertoni IUGR/SGA

17 Pulsatility Index = PI 10 0 cm/s PI = A B V 50 A V 0 B

18 Intrauterin tillväxthämning Vanligast är placentainsufficiens SGA foster inga maternella symptom

19 Screening för IUGR a) symfys-fundus mätningar

20 Screening för IUGR b) rutinmässig ultraljudsfetometri i tredje trimestern (32 v.) viktavvikelse -10 till -21% viktavvikelse < -21% (SGA) kontroll ultraljud fosterövervakning

21 Fosterövervakning av graviditeter med IUGR Doppler velocimetri antenatal kardiotokografi (CTG) upprepad fetometri fosteraktivitet fostervattenmängd (amniotic fluid index AFI)

22 Doppler ultraljud A. umbilicalis

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24 BLODFLÖDESKLASSER BFC norm BFC I BFC II BFC III A BFC III B

25 Meta-analysis - perinatal mortality Study Treatment Control OR; 95% CI London 8/233 9/ ; Maastricht 1/73 2/ ; Sweden 0/214 2/ ; Tygerberg 6/108 8/ ; Edinburgh 1 1/370 3/ ; Bradford 1/73 1/ ; Chester 1/338 3/ ; Dublin 3/240 2/ ; Edinburgh 2 5/722 2/ ; Perth 7/231 7/ ; Leeds 1/248 2/ ; Oxford 3/437 8/ ; Sidney 0/126 2/ ; Utrecht 10/790 18/ ; Overall 47/ / ;

26 Umbilical artery Doppler - high risk pregnancy Westergaard et al. Ultrasound Obstet Gynecol 2001 Odds Ratio (95% CI) Perinatal mortality Inductions of labor Antenatal admission Caesarean sections 0.67; ; ; ;

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28 CTG

29 CTG Baseline

30 CTG

31 Normal CTG Accelerations

32 CTG Decelerations

33 Patological CTG Decelerations Reduced variability

34 Uteruskontraktioner

35 Accelerationer Variabilitet Basal frequens Decelerationer Uteruskontraktioner

36 Non-stress test - normal reaktiv CTG kurva

37 Non-stress test - patologisk CTG registrering

38 Vetter, 1999

39 STAN

40 STAN guidelines

41 IUGR - behandling: Tecken på hotande fosterasfyxi förlossning (ca 40 % av IUGR kejsarsnitt)

42 Sequential changes in tests of fetal well being in uteroplacental failure Growth Cerebral blood flow Aortic blood flow Fetal size < 5th centile ± Umbilical artery PI Moderate to severe redistributi on Abnormal venous blood flow Abnormal FHR trace Harrington and Campbell, 1995 Amniotic fluid ± volume Oligohydramnios