Professional Documents
Culture Documents
Prediction and Prevention RCIU PDF
Prediction and Prevention RCIU PDF
PE and IUGR
Eduard Gratacos
www.medicinafetalbarcelona.org
www.medicinafetalbarcelona.org/
Preeclampsia
IUGR
www.medicinafetalbarcelona.org/
Normal and
abnormal
placental
implantation
www.medicinafetalbarcelona.org/
EARLY-ONSET PE AND IUGR
Relation between placental and maternal disease
HTA
PREDISPOSITION
Endothelial disease
MOTHER proteinuria
DAMAGE platelets
hemolysis
DYSFUNCTION
liver
HYPERSTIMULATION HELLP
eclampsia
IUGR
Endothelial disease
(poor implantation) Fetal hypoxia
PLACENTA
DPPNI
www.medicinafetalbarcelona.org/
EARLY-ONSET LATE-ONSET
4-8 %
PREECLAMPSIA
1%
PREECLAMPSIA + IUGR
1%
IUGR
4-8 %
35 40
20 25 30
www.fetalmedicinebarcelona.org/
PREECLAMPSIA
Disease of the vascular endothelium which requires
Gestational
Age
MATERNAL
PREDISPOSITION
ANOMALOUS
PLACENTATION
www.medicinafetalbarcelona.org/
%
34 10
5
PE
0
20 25 30 35 40
www.medicinafetalbarcelona.org/
PREECLAMPSIA: EARLY VERSUS LATE
EARLY LATE
(<34w) (>34w)
Abnormal placental
+++ +
pathology
www.medicinafetalbarcelona.org/
Prediction of PE
11-14w
PE
INTEGRATED FIRST TRIMESTER APPROACH
maternal + UtA Doppler + biomarkers
80-90% 25-50%
www.medicinafetalbarcelona.org/
Prediction of PE
11-14w
PE
INTEGRATED FIRST TRIMESTER APPROACH
maternal + UtA Doppler + biomarkers
www.medicinafetalbarcelona.org/
Epidemiological
risk PREECLAMPSIA
www.medicinafetalbarcelona.org/
Prediction of PE
11-14w
PE
INTEGRATED FIRST TRIMESTER APPROACH
maternal + UtA Doppler + biomarkers
50% 25%
www.medicinafetalbarcelona.org/
Uterine
Artery
Doppler
www.medicinafetalbarcelona.org/
Before
pregnancy
6-12 w
16-24 w
www.medicinafetalbarcelona.org/
Transvaginally
Feasible throughout pregnancy
Sagittal plane
Measurement at the internal cervical os level
Transabdominally
Feasible after 12 weeks
Lateral plane
Measurement at the crossover with the iliac artery
www.medicinafetalbarcelona.org/
www.medicinafetalbarcelona.org/
www.medicinafetalbarcelona.org/
www.medicinafetalbarcelona.org/
www.medicinafetalbarcelona.org/
www.medicinafetalbarcelona.org/
www.medicinafetalbarcelona.org/
www.medicinafetalbarcelona.org/
www.medicinafetalbarcelona.org/
www.medicinafetalbarcelona.org/
www.medicinafetalbarcelona.org/
www.medicinafetalbarcelona.org/
www.medicinafetalbarcelona.org/
www.medicinafetalbarcelona.org/
Iliac
art.
www.medicinafetalbarcelona.org/
www.medicinafetalbarcelona.org/
UtA
Doppler:
QuanKtaKve
assessment
PulsaKlity
index
4,0
3,0
2,0
1,0
0
10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40 42
Gmez
O,
Figueras
F.
Reference
ranges
for
uterine
artery
mean
pulsaKlity
index
at
11-41
weeks
of
gestaKon.
Ultrasound
Obstet
Gynecol.
2008
Aug;32(2):128-32
www.medicinafetalbarcelona.org/
Prediction of PE
11-14w
PE
INTEGRATED FIRST TRIMESTER APPROACH
maternal + UtA Doppler + biomarkers
80-90% 25-50%
www.medicinafetalbarcelona.org/
Biomarkers 1T and PE
DR (FP 10%)
Early PE Late PE
PlGF 60% -
sEng 47% -
PP13 38% -
www.medicinafetalbarcelona.org/
Poon 2009, Akolekar 2009, Poon 2010, Audibert 2010, Foidart 2010, Wortelboer 2010,
www.medicinafetalbarcelona.org/
www.medicinafetalbarcelona.org/
High risk of PE: management
www.medicinafetalbarcelona.org/
Prediction of PE
11-14w
PE
INTEGRATED FIRST TRIMESTER APPROACH
maternal + UtA Doppler + biomarkers
80-90% 25-50%
www.medicinafetalbarcelona.org/
Prediction of PE
32-34w
PE
THIRD TRIMESTER APPROACH
maternal OR UtA Doppler OR biomarkers
www.medicinafetalbarcelona.org/
EARLY-ONSET PE
First T combined algorithms=90% DR (10% FPR)
AAS 100 mg/24 h seem to reduce risk
LATE-ONSET IUGR
Detection in 1T still very low.
Future: 3rd T strategies improving definition
www.fetalmedicinebarcelona.org/
Preeclampsia
IUGR
www.medicinafetalbarcelona.org/
N
cases
UA Doppler +
(EARLY-ONSET)
UA Doppler N
(LATE-ONSET)
N cases
Savchev
2013
GA@diagnosis 20 25 30 35 40
32w @diagnosis
Placental disease: high (UA+, PE high) Placental disease: low (UA-, PE low)
High mortality and morbidity Low mortality but poor long outcome.
www.fetalmedicinebarcelona.org/
signs perinatal
adaptation outcome
%
3
yes poorer
IUGR
CLINICAL PROBLEMS
3
SGA
no normal 0
PROBLEM 1: DIAGNOSIS
20 detection
25<50% 30 35 40
www.fetalmedicinebarcelona.org/
Neonatal and Fetal GA-adjusted normal
weight in the same population
www.fetalmedicinebarcelona.org/
PROBLEM 1: IMPROVING DETECTION: THE DEFINITION OF RESTRICTION
Birthweight inverse relation with perinatal outcome AND brain-cardiac remodelling
INDIVIDUAL
BIOMARKERS
INTERVENTION
WINDOW OF
OPPORTUNITY
BIRTH
Fetus Child
Func4onal
/
structural
organ
remodeling Problem
evident
www.fetalmedicinebarcelona.org/
KEY ISSUE TO IMPROVE OUTCOMES IS EARLY
DETECTION AND TIMELY INTERVENTION
LATE-ONSET PE
Poor prediction in 1st T.
Future: 3rd T strategies
LATE-ONSET IUGR
Detection is still very low.
Future: 3rd T strategies improving definition
www.fetalmedicinebarcelona.org/