CRECIMIENTO INTRAUTERINO RESTRINGIDO:

MANEJO
Eduard Gratacós

BCNatal – Barcelona Center of Maternal-Fetal and Neonatal Medicine

Hospital Clínic and Hospital Sant Joan de Déu, Universitat de Barcelona
www.fetalmedicinebarcelona.org/

www.fetalmedicinebarcelona.org/
 IUFD: 3% No stillbirths

1. DETECTAR FETO
PEQUEÑO

UTILIZAR UN PROTOCOLO
2. CLASIFICAR PEG VS CIR
(adaptado al entorno clínico)

3. DEFINIR ESTADIO Y
FINALIZACIÓN

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 CIR: 1 protocolo, 2 escenarios clínicos

Early-severe Late-mild

50%
10%
Asociación a PE

Riesgo muerte/resultado adverso Alto Si CIR: a partir 37s

Preguntas clínicas Finalizar? Nueva evaluación? Alto riesgo (finalizar a término)?

Paso relevante del protocolo #3: Definir estadio gravedad #2: Definir si es CIR o PEG

Savchev 2013
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 PROTOCOLO PASO #2: DEFINIR SI ES CIR O PEG

PLACENTAL DISEASE HYPOXIA ACIDOSIS SERIOUS INJURY DEATH

Diagnostic/chronic markers
DIFFERENCE
FGR VS SGA

Increment placental
impedance

Centralization

cardiac ischemia
Diastolic failure

Systolic cardiac
failure

deliver when risks are:

Risks of
MINIMAL MILD MODERATE HIGH VERY HIGH
prematurity

www.fetalmedicinebarcelona.org/
 PROTOCOLO PASO 3: DEFINIR ESTADIO GRAVEDAD CIR

PLACENTAL DISEASE HYPOXIA ACIDOSIS SERIOUS INJURY DEATH

Diagnostic/chronic markers Prognostic/Acute markers
DIFFERENCE INDICATION ABOUT THE SHORT-TERM RISK
FGR VS SGA OF IUFD/BRAIN INJURY

Increment placental
impedance

Centralization

cardiac ischemia
Diastolic failure

cCTG: reduced STV

BPP < 6
Systolic cardiacCGTdec
failure
Stage fetal
deterioration I II III IV
deliver when risks are:
Risks of
MINIMAL MILD MODERATE HIGH VERY HIGH
prematurity

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 early-severe FGR
CONSIDERACIONES
PRÁCTICAS
Management protocol according to severity stages
-<28s EG factor más
importante (valorar
expectante)

-Combinar siempre
BPP <6 Doppler y RCTG

-si PE: usar los 2

2-4 weeks 1-2 weeks 4-7 days 1-2 days Hours protocolos

Stage II Stage III Stage IV -Corticoides+ SO4Mg

según protocolo

Delivery 34w (/2-3d) 30w (/d) Any time (consider expectant if <28w)
(follow up)

Ferrazzi 2002, Baschat 2003, Hecher 2003, Baschat 2007

Grivell 2009, Kafur 2008, Lalor 2010, Crispi 2009
Cruz-Lemini 2012, TRUFFLE 2015

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 FGR: TREATMENT OPTIONS?

PREVENTION (NOT TX)

Aspirin (ASA) ✅
HEPARIN (LMWH) ❌

TREATMENT
Sidenafil ❌
Statins
?

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 CONTROL CIR EN ENTORNO SUB-ÓPTIMO

1-NO DOPPLER CIR TARDÍO: finalizar 37s

2-NO DOPPLER EN CIR PRECOZ: finalizar 32-34s

3-DV NO EXPERIENCIA: usar solo AU, definir est. IV por RCTG

4-ESTADIO II: CONTROL/2-3d NO POSIBLE: finalizar 32s

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 Integrated
Management of IUGR
1. Identify small fetus EFW < p10

2. Distinguish CPR, UtA, EFW<p3

SGA vs FGR

SGA FGR

3. Timing delivery 40 w (/2w)

and follow up I 37w (/w)

II 34w (/2-3d)

III 30w (/d)

IV Any time

Figueras & Gratacos 2014

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Early and late onset FGR = different clinical scenarios and needs
HOWEVER, NO NEED FOR DIFFERENT PROTOCOLS

Early-severe Late-mild
High risk IUFD preterm No IUFD <37w (risk at term)
PROBLEM: TIMING DELIVERY PROBLEM: DETECTION
Q: Delivery? Next exam? Q: Is it FGR or SGA?

Stage II to IV Stage I
PROTOCOL Deliver 37w

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 1. Identification of “small fetus”
(=is it small?)

2. Distinguish SGA vs FGR

(=is elective delivery at term indicated?)
LATE
High-risk (FGR) vs low-risk (SGA) small fetus IUGR

3. Decide follow-up + timing delivery

(=is there an indication to deliver <37w?)
EARLY
IUGR

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