Intrauterin tillväxthämning
Intrauterin tillväxthämning IUGR = Intrauterine growth restriction vs. SGA = small for gestational age
Biparietal diameter (BPD) Femurlängd (FL) FL Bukdiameter (AD) AD
Fetal weight (g) LGA fetus AGA fetus SGA fetus SGA fetus Gestational age (weeks)
Fetal weight (g) SGA Gestational age (weeks)
Fetal weight (g) IUGR + SGA Gestational age (weeks)
Fetal weight (g) IUGR AG A SGA IUGR Gestational age (weeks)
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
Intrauterin tillväxthämning Fetala faktorer - kromosomala avvikelser (trisomi 13, 18) - kongenitala malformationer - infektioner cytomegalovirus toxoplasmos malaria
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)
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
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
SGA 3 rd centile Ødegard R et al. Obstet Gynecol 2000 Preeclampsia Controls % 95% CI % Overall 12 3 Mild 6 1-10 Moderate 12 6-17 Severe 21 12-29 Late PE (> 32 wks) 7 4-10 Early PE (< 32 wks) 53 36-70
Uterine artery Doppler
Doppler ultralyd - uterin artärene Diastolisk notch och hög PI Före 22-24 veckor - Fysiologisk (15%) Efter 24 veckor - Indikerar utveckling av Preeklampsi Hypertoni IUGR/SGA
Pulsatility Index = PI 10 0 cm/s PI = A B V 50 A V 0 B
Intrauterin tillväxthämning Vanligast är placentainsufficiens SGA foster inga maternella symptom
Screening för IUGR a) symfys-fundus mätningar
Screening för IUGR b) rutinmässig ultraljudsfetometri i tredje trimestern (32 v.) viktavvikelse -10 till -21% viktavvikelse < -21% (SGA) kontroll ultraljud fosterövervakning
Fosterövervakning av graviditeter med IUGR Doppler velocimetri antenatal kardiotokografi (CTG) upprepad fetometri fosteraktivitet fostervattenmängd (amniotic fluid index AFI)
Doppler ultraljud A. umbilicalis
BLODFLÖDESKLASSER BFC norm BFC I BFC II BFC III A BFC III B
Meta-analysis - perinatal mortality Study Treatment Control OR; 95% CI London 8/233 9/226 0.86; 0.33-2.26 Maastricht 1/73 2/75 0.52; 0.05-5.11 Sweden 0/214 2/211 0.13; 0.01-2.13 Tygerberg 6/108 8/104 0.71; 0.24-2.09 Edinburgh 1 1/370 3/384 0.38; 0.05-2.71 Bradford 1/73 1/77 1.06; 0.07-17.1 Chester 1/338 3/335 0.36; 0.05-2.59 Dublin 3/240 2/234 1.46; 0.25-8.49 Edinburgh 2 5/722 2/763 2.50; 0.57-11.0 Perth 7/231 7/230 1.00; 0.34-2.88 Leeds 1/248 2/249 0.51; 0.05-4.97 Oxford 3/437 8/459 0.42; 0.13-1.38 Sidney 0/126 2/159 0.17; 0.01-2.71 Utrecht 10/790 18/756 0.53; 0.25-1.13 Overall 47/4230 69/4262 0.67; 0.47-0.97
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; 0.47-0.97 0.78; 0.63-0.96 0.56; 0.43-0.72 0.78; 0.65-0.94 0 1 5
CTG
CTG Baseline
CTG
Normal CTG Accelerations
CTG Decelerations
Patological CTG Decelerations Reduced variability
Uteruskontraktioner
Accelerationer Variabilitet Basal frequens Decelerationer Uteruskontraktioner
Non-stress test - normal reaktiv CTG kurva
Non-stress test - patologisk CTG registrering
Vetter, 1999
STAN
STAN guidelines
IUGR - behandling: Tecken på hotande fosterasfyxi förlossning (ca 40 % av IUGR kejsarsnitt)
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