beleid bij preterme iugr · 2020. 4. 14. · •truffle ii o inclusion criteria • singleton...
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Beleid bij IUGRPentalfa 10 oktober 2019
Prof Dr J Richter
Inhoud Definition Follow-up Delivery : When? How? Why?
Definition
Ganzevoort et al, UOG 2016
Definition• Small baby
o Constitutional small?o Placental insufficiency ?o Chromosomal/genetic abnormality ?
• Risk 1%o Congenital infection ?
• TORCH 0.5%, mostly CMV
Definition• Delphi consensus: early and late-onset
Ganzevoort et al, UOG 2016
Definition
Early IUGR (<32 weeks)
Early IUGR (< 32 weeks)
Cole et al, Arch Dis Child Fetal Neonatal Ed 2010
Early IUGR – follow-up
Baschat, Best Practice 2018
Early IUGR – follow-up
Figueras et at, FDT 2014
Early IUGR – follow-up • TRUFFLE I
o Trial of Randomized Umbilical and Fetal FLow in Europeo 20 centers 2005-2010o Growth <P10 between 26-32 weekso 3 randomisation groups
• CTG: STV below threshold• Early ductal changes• Late ductal changes
Early IUGR – follow-up • TRUFFLE I
o Safety neto Outcome
• Composite fetal/neonatal death• Morbidity
o 503 inclusions• 2,4% fetal death• 5,5% neonatal death
Early IUGR – TRUFFLE I • Composite outcome death/morbidity
o N= 157 (=31%)• 70% liveborn: without severe morbidity• Determinants poor outcome
o Hypertension at entry: OR 1.7o GA at entry: OR 0.8 per week of gestationo EFW at entry: OR 0.84 per 100g
Early IUGR – TRUFFLE I
Early IUGR – decision making
Early IUGR – decision making
Early IUGR – conclusion• Diagnosis
o Consider DD (infection/genetic/constitutional)• Follow-up
o Active management: discuss!• 24w? 26w? 28w?
o IUGR with abnl dopplers: daily CTG – dopplers 2/wo Maternal follow-up!
• Delivery o As late as possibleo Cesarean section
Late IUGR (> 32 weeks)
Late IUGR – harmless?• SGA at term: IUD x2
o 9.7/1000 detected 18.9/1000 undetected• FGR at term: IUD x4• Neonatal death SGA at term x2,5
o 1,1/1000 vs 0,4/1000• Neurological outcome?
o Adverse outcome at birth x1,4 (1,1% vs 0,7%)o Neurodevelopmental score -0,3SDo Poor school outcome x1,5-1,8
Figueras et al, Best Practice 2017
Late IUGR – follow-up• CPR?• AU?• UA?• MCA?
Late IUGR – management • Digitat-study
o Randomisation induction vs expectanto >36w and suspected FRF/SGAo Outcome
• 10d earlier – 130g lighter• Primary and secondary comparable
Boers et at, BMJ 2010
Late IUGR – management • Risk stratification protocol
o SGA (<P10) and >36w GA, nl doppler UmbAo Induction only at 37w in high risk population
• EFW <P3• CPR <P5• UtA >P95 at midgestation• PAPP-A <0,3MoM• Gestational hypertension
o No risk factors: • P3-P5: weekly ultrasound and delivery 40w• P5-P10: US every 2w and delivery 41w
Veglia et at, UOG 2018
Late IUGR – management
IUGR – management
Figueras et at, FDT 2014
Late IUGR – management???• TRUFFLE II
o INCLUSION CRITERIA• Singleton fetuses at risk of compromise: • between 32+0 and 36+6 weeks of gestation and• estimated fetal weight or abdominal circumference <10th percentile OR drop from 18-22 week scan of
50 percentile points and:o Eligibility for randomisation
• cerebral redistribution defined as UCR z-score 1.5 (32-33+6 weeks), 1.0 (34-36+6 weeks) and:• normal STV on cCTG (> 4.5msec) and:• no contraindications to either trial treatment arm
• START 2020
IUGR• Take home management
o Early vs late IUGR• Diagnosis >< management
o Pathology and dopplers differ in both entitieso Wait as long as reasonable
• Time consuming in early IUGR !!• Consider “non”viable >26w
o Truffle II might produce more firm protocol for >32w
