CIR PRECOZ Y TARDÍO - medicinafetalbarcelona · CIR PRECOZ Y TARDÍO Eduard Gratacos Servicio de...
Transcript of CIR PRECOZ Y TARDÍO - medicinafetalbarcelona · CIR PRECOZ Y TARDÍO Eduard Gratacos Servicio de...
www.fetalmedicinebarcelona.org/
CIR PRECOZ Y TARDÍOEduard Gratacos
Servicio de Medicina MaternofetalHospital Clinic y Hospital Sant Joan de Deu - Universidad de Barcelona
www.fetalmedicinebarcelona.org
martes 18 de junio de 13
www.medicinafetalbarcelona.org/
1. CIR vs. PEG
2. Precoz vs. Tardío
3. Implicación en el manejo clínico
martes 18 de junio de 13
www.medicinafetalbarcelona.org/
1. CIR vs. PEG
2. Precoz vs. Tardío
3. Implicación en el manejo clínico
martes 18 de junio de 13
www.medicinafetalbarcelona.org/
The discovery of UA and hemodynamics of IUGR
Savchev 2013
martes 18 de junio de 13
www.medicinafetalbarcelona.org/
Constitutionally small Placental insufficiency Extrinsic cause
Primary fetal defect
The discovery of UA and hemodynamics of IUGR
IUGR = abnormal UA Doppler
Savchev 2013
martes 18 de junio de 13
www.medicinafetalbarcelona.org/
Constitutionally small Placental insufficiency Extrinsic cause
Primary fetal defect
SGA IUGR
The discovery of UA and hemodynamics of IUGR
IUGR = abnormal UA Doppler
Savchev 2013
martes 18 de junio de 13
www.medicinafetalbarcelona.org/
Constitutionally small Placental insufficiency Extrinsic cause
Primary fetal defect
SGA IUGR
The discovery of UA and hemodynamics of IUGR
IUGR = abnormal UA Doppler
20 30 4025 35 Savchev 2013
martes 18 de junio de 13
www.medicinafetalbarcelona.org/
Constitutionally small Placental insufficiency Extrinsic cause
Primary fetal defect
SGA IUGR
The discovery of UA and hemodynamics of IUGR
IUGR = abnormal UA Doppler
20 30 4025 35
0
N cases
N cases
Savchev 2013
martes 18 de junio de 13
www.medicinafetalbarcelona.org/
Constitutionally small Placental insufficiency Extrinsic cause
Primary fetal defect
SGA IUGR
The discovery of UA and hemodynamics of IUGR
IUGR = abnormal UA Doppler
20 30 4025 35
0
N cases
N cases
Savchev 2013
martes 18 de junio de 13
www.medicinafetalbarcelona.org/
Constitutionally small Placental insufficiency Extrinsic cause
Primary fetal defect
SGA IUGR
The discovery of UA and hemodynamics of IUGR
IUGR = abnormal UA Doppler
20 30 4025 35
0
N cases
N cases
UA Doppler +(EARLY-ONSET)
Savchev 2013
martes 18 de junio de 13
www.medicinafetalbarcelona.org/
Constitutionally small Placental insufficiency Extrinsic cause
Primary fetal defect
SGA IUGR
The discovery of UA and hemodynamics of IUGR
IUGR = abnormal UA Doppler
20 30 4025 35
0
N cases
N cases
UA Doppler +(EARLY-ONSET)
UA Doppler N(LATE-ONSET)
Savchev 2013
martes 18 de junio de 13
www.medicinafetalbarcelona.org/
Significant increase in the risk of adverse perinatal outcome
Hershkovitz et al. Ultrasound Obstet Gynecol 2000
Severi et al. Ultrasound Obstet Gynecol 2002
Figueras et al . Eur J Obstet Gynecol Reprod Biol 2008
e<p95
SGA
SGA = constitutionally small?
martes 18 de junio de 13
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Significant increase in the risk of adverse perinatal outcome
Hershkovitz et al. Ultrasound Obstet Gynecol 2000
Severi et al. Ultrasound Obstet Gynecol 2002
Figueras et al . Eur J Obstet Gynecol Reprod Biol 2008
e<p95
SGA
SGA = constitutionally small?
Significant increase in the risk of adverse neurodevelopment
Eixarch et al. Ultrasound Obstet Gynecol 2008
Severi et al. Ultrasound Obstet Gynecol 2002
Figueras et al . Eur J Obstet Gynecol Reprod Biol 2008
martes 18 de junio de 13
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0
10
20
30
40
Neonatal acidosis CS for distress Abnormal NBAS Any
%
Figueras 2011
SGA: proportion of perinatal adverse outcomes in 376 consecutive cases
martes 18 de junio de 13
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Neurobehavioral performance of term SGA newborns
* **
**
* p <0.05Adjusted for GA, maternal age, socioeconomic status and smoking
N=120 SGA vs
100 AGA
martes 18 de junio de 13
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Neurobehavioral performance of term SGA newborns
* **
**
* p <0.05Adjusted for GA, maternal age, socioeconomic status and smoking
Satchev, 2012Geva 2008
Figueras 2008Eixarch 2010
N=120 SGA vs
100 AGA
* * *
Bay
ley
Sco
re
20
40
60
80
100
120
cognitive language motor socio-emotional adaptivebehavior
* * *
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control IUGR
Crispi 2010
Cardiovascular programming in SGA / late-IUGR
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control IUGR
Crispi 2010
Cardiovascular programming in SGA / late-IUGRFetuses EFW<p10 evaluated at 5 years
Classified by CPR, p3 and UtA Doppler:•All normal: SGA•Any abnormal: late-IUGR
martes 18 de junio de 13
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control IUGR
Crispi 2012
Crispi 2010
Cardiovascular programming in SGA / late-IUGRFetuses EFW<p10 evaluated at 5 years
Classified by CPR, p3 and UtA Doppler:•All normal: SGA•Any abnormal: late-IUGR
martes 18 de junio de 13
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IMPACT OF NON-DETECTED IUGR ON LATE FETAL MORTALITYHospital Clínic Barcelona2005-2010
0%
10%
20%
30%
40%
50%
FGR Unknown Others
25%30%
45%
Relevant Condition ReCoDe
martes 18 de junio de 13
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IMPACT OF NON-DETECTED IUGR ON LATE FETAL MORTALITYHospital Clínic Barcelona2005-2010
0%
10%
20%
30%
40%
50%
FGR Unknown Others
25%30%
45%
Relevant Condition ReCoDe
Classification of stillbirth by relevant condition at birth (ReCoDe): population-based cohort studyGardosi et al. BMJ 2005, 2010
N=2625 stillbirths
FGR as relevant condition identified in 43-60%
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FETAL DETERIORATION IN PLACENTAL INSUFFICIENCY EARLY VS LATE IUGR (>34s)
PLACENTAL DISEASE COMPENSATED HYPOXIA DECOMPENSATED HYPOXIA SERIOUS INJURYDEATH
cardiac ischemiaDiastolic failure
Systolic cardiac failure
Centralization
Increment placental impedance
growth
MIDDLE CEREBRAL A.
UMBILICAL A.
DUCTUS VENOSUS
CTG / BPP ABNORMAL
martes 18 de junio de 13
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FETAL DETERIORATION IN PLACENTAL INSUFFICIENCY EARLY VS LATE IUGR (>34s)
PLACENTAL DISEASE COMPENSATED HYPOXIA DECOMPENSATED HYPOXIA SERIOUS INJURYDEATH
cardiac ischemiaDiastolic failure
Systolic cardiac failure
Centralization
Increment placental impedance
growth
MIDDLE CEREBRAL A.
UMBILICAL A.
DUCTUS VENOSUS
CTG / BPP ABNORMAL
Placental injury <30%
martes 18 de junio de 13
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FETAL DETERIORATION IN PLACENTAL INSUFFICIENCY EARLY VS LATE IUGR (>34s)
PLACENTAL DISEASE COMPENSATED HYPOXIA DECOMPENSATED HYPOXIA SERIOUS INJURYDEATH
cardiac ischemiaDiastolic failure
Systolic cardiac failure
Centralization
Increment placental impedance
growth
MIDDLE CEREBRAL A.
UMBILICAL A.
DUCTUS VENOSUS
CTG / BPP ABNORMAL
Placental injury <30%
martes 18 de junio de 13
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FETAL DETERIORATION IN PLACENTAL INSUFFICIENCY EARLY VS LATE IUGR (>34s)
PLACENTAL DISEASE COMPENSATED HYPOXIA DECOMPENSATED HYPOXIA SERIOUS INJURYDEATH
cardiac ischemiaDiastolic failure
Systolic cardiac failure
Centralization
Increment placental impedance
growth
MIDDLE CEREBRAL A.
UMBILICAL A.
DUCTUS VENOSUS
CTG / BPP ABNORMAL
Placental injury <30%
mild hypoxiano cardiovascular adaptation
martes 18 de junio de 13
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FETAL DETERIORATION IN PLACENTAL INSUFFICIENCY EARLY VS LATE IUGR (>34s)
PLACENTAL DISEASE COMPENSATED HYPOXIA DECOMPENSATED HYPOXIA SERIOUS INJURYDEATH
Centralization
Increment placental impedance
growth
MIDDLE CEREBRAL A.
UMBILICAL A.
CTG / BPP ABNORMAL
Placental injury <30%
mild hypoxiano cardiovascular adaptation
martes 18 de junio de 13
www.medicinafetalbarcelona.org/
FETAL DETERIORATION IN PLACENTAL INSUFFICIENCY EARLY VS LATE IUGR (>34s)
PLACENTAL DISEASE COMPENSATED HYPOXIA DECOMPENSATED HYPOXIA SERIOUS INJURYDEATH
Centralization
Increment placental impedance
growth
MIDDLE CEREBRAL A.
UMBILICAL A.
CTG / BPP ABNORMAL
Placental injury <30%
mild hypoxiano cardiovascular adaptation
minimal tolerance to hypoxia
martes 18 de junio de 13
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FETAL DETERIORATION IN PLACENTAL INSUFFICIENCY EARLY VS LATE IUGR (>34s)
PLACENTAL DISEASE DECOMPENSATED HYPOXIA SERIOUS INJURYDEATH
Centralization
Increment placental impedance
growth
MIDDLE CEREBRAL A.
UMBILICAL A.
CTG / BPP ABNORMAL
Placental injury <30%
mild hypoxiano cardiovascular adaptation
minimal tolerance to hypoxia
martes 18 de junio de 13
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Distribution of cases when IUGR = abnormal UA Doppler
Savchev 2013
martes 18 de junio de 13
www.medicinafetalbarcelona.org/
Distribution of cases when IUGR = abnormal CPR or UtA or EFW<p3
Savchev 2013
martes 18 de junio de 13
www.medicinafetalbarcelona.org/
1. CIR vs. PEG
2. Precoz vs. Tardío
3. Implicación en el manejo clínico
martes 18 de junio de 13
www.fetalmedicinebarcelona.org/
IUGR
SGA?
20 30 4025 35
0
3
6 %
IUGR= low CPR or high UtA or EFW<p3 or low PlGF
martes 18 de junio de 13
www.fetalmedicinebarcelona.org/
IUGR
SGA?
20 30 4025 35
0
3
6 %
IUGR= low CPR or high UtA or EFW<p3 or low PlGF
32w @diagnosis
martes 18 de junio de 13
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IUGR
SGA?
20 30 4025 35
0
3
6 %
IUGR= low CPR or high UtA or EFW<p3 or low PlGF
EARLY IUGR (1%) LATE IUGR (5-7%)
32w @diagnosis
martes 18 de junio de 13
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IUGR
SGA?
20 30 4025 35
0
3
6 %
IUGR= low CPR or high UtA or EFW<p3 or low PlGF
EARLY IUGR (1%) LATE IUGR (5-7%)
PROBLEM: MANAGEMENT PROBLEM: DIAGNOSIS
32w @diagnosis
martes 18 de junio de 13
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IUGR
SGA?
20 30 4025 35
0
3
6 %
IUGR= low CPR or high UtA or EFW<p3 or low PlGF
EARLY IUGR (1%) LATE IUGR (5-7%)
PROBLEM: MANAGEMENT PROBLEM: DIAGNOSIS
Placental disease: high (UA+, PE high) Placental disease: low (UA-, PE low)
32w @diagnosis
martes 18 de junio de 13
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IUGR
SGA?
20 30 4025 35
0
3
6 %
IUGR= low CPR or high UtA or EFW<p3 or low PlGF
EARLY IUGR (1%) LATE IUGR (5-7%)
PROBLEM: MANAGEMENT PROBLEM: DIAGNOSIS
Placental disease: high (UA+, PE high) Placental disease: low (UA-, PE low)
Hypoxia ++: systemic CV adaptation Hypoxia +/-: central CV adaptation
32w @diagnosis
martes 18 de junio de 13
www.fetalmedicinebarcelona.org/
IUGR
SGA?
20 30 4025 35
0
3
6 %
IUGR= low CPR or high UtA or EFW<p3 or low PlGF
EARLY IUGR (1%) LATE IUGR (5-7%)
PROBLEM: MANAGEMENT PROBLEM: DIAGNOSIS
Placental disease: high (UA+, PE high) Placental disease: low (UA-, PE low)
Hypoxia ++: systemic CV adaptation Hypoxia +/-: central CV adaptation
Tolerance to hypoxia. Natural history Low tolerance: no natural history
32w @diagnosis
martes 18 de junio de 13
www.fetalmedicinebarcelona.org/
IUGR
SGA?
20 30 4025 35
0
3
6 %
IUGR= low CPR or high UtA or EFW<p3 or low PlGF
EARLY IUGR (1%) LATE IUGR (5-7%)
PROBLEM: MANAGEMENT PROBLEM: DIAGNOSIS
Placental disease: high (UA+, PE high) Placental disease: low (UA-, PE low)
Hypoxia ++: systemic CV adaptation Hypoxia +/-: central CV adaptation
Tolerance to hypoxia. Natural history Low tolerance: no natural history
High mortality and morbidity Low mortality but poor long outcome.
32w @diagnosis
martes 18 de junio de 13
Perinatal >90% 30-‐40% <10%Mortality
www.medicinafetalbarcelona.org/
<26 26-28 >28
Baschat 2003Hecher 2003 Grivell 2010Cruz-‐Lemini 2012
Early-onset IUGRPROBLEM #1: MORTALITY
martes 18 de junio de 13
Perinatal >90% 30-‐40% <10%Mortality
www.medicinafetalbarcelona.org/
<26 26-28 >28
Baschat 2003Hecher 2003 Grivell 2010Cruz-‐Lemini 2012
Early-onset IUGRPROBLEM #1: MORTALITY
DVa (rev)
Yes No
60%
19%
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Perinatal >90% 30-‐40% <10%Mortality
www.medicinafetalbarcelona.org/
<26 26-28 >28
Baschat 2003Hecher 2003 Grivell 2010Cruz-‐Lemini 2012
Early-onset IUGRPROBLEM #1: MORTALITY
DVa (rev)
Yes No
60%
19%
cCTG-‐STV<3 ms
Pathological CGT
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Perinatal >90% 30-‐40% <10%Mortality
www.medicinafetalbarcelona.org/
<26 26-28 >28
Baschat 2003Hecher 2003 Grivell 2010Cruz-‐Lemini 2012
Early-onset IUGRPROBLEM #1: MORTALITY
DVa (rev)
Yes No
60%
19%
cCTG-‐STV<3 ms
Pathological CGT
BPPIUFD 23% in BPP=6 and 11% in BPP=8
Poor correlation with DVa(rev)Cochrane: poor contribution to prediction
Baschat 2007, Kafur 2008, Lalor 2010, Crispi 2009
martes 18 de junio de 13
Neurologic >90% 30-‐40% <10%Morbidity
www.medicinafetalbarcelona.org/
<29 29-32 >32.0
Fouron 2004Del Rio 2008Cruz-‐MarQnez 2012
Early-onset IUGRPROBLEM #2: (NEUROLOGICAL) MORBIDITY
martes 18 de junio de 13
Neurologic >90% 30-‐40% <10%Morbidity
www.medicinafetalbarcelona.org/
<29 29-32 >32.0
Fouron 2004Del Rio 2008Cruz-‐MarQnez 2012
Early-onset IUGRPROBLEM #2: (NEUROLOGICAL) MORBIDITY
0
15
30
45
60
(%)
ControlsIUGR antegrade AoIIUGR retrograde AoI
ControlsIUGR DV<5 z-scoreIUGR DV>5 z-score
**
Brain US anomalies in 30w IUGR
martes 18 de junio de 13
Neurologic >90% 30-‐40% <10%Morbidity
www.medicinafetalbarcelona.org/
<29 29-32 >32.0
Fouron 2004Del Rio 2008Cruz-‐MarQnez 2012
Early-onset IUGRPROBLEM #2: (NEUROLOGICAL) MORBIDITY
0
15
30
45
60
(%)
ControlsIUGR antegrade AoIIUGR retrograde AoI
ControlsIUGR DV<5 z-scoreIUGR DV>5 z-score
**
Brain US anomalies in 30w IUGR
martes 18 de junio de 13
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• 5-7% newborns• detection < 50%• > 40% late pregnancy IUFD• Neurological, cardiovascular and
metabolic impact• diagnosis SGA vs. Late-IUGR
IUGR
SGA?
20 30 4025 35
0
3
3%
martes 18 de junio de 13
www.medicinafetalbarcelona.org/
• 5-7% newborns• detection < 50%• > 40% late pregnancy IUFD• Neurological, cardiovascular and
metabolic impact• diagnosis SGA vs. Late-IUGR
IUGR
SGA?
20 30 4025 35
0
3
3%
CLINICAL PROBLEMS
# 1: DIAGNOSISdetection <50%
# 2: POOR PERINATAL OUTCOME (∼50%)• A “Late-IUGR subset” with poorer perinatal
outcome can be identified
# 3: LONG TERM OUTCOME (∼50%)Fetal programming
No means to select high risk groups
martes 18 de junio de 13
www.medicinafetalbarcelona.org/
• 5-7% newborns• detection < 50%• > 40% late pregnancy IUFD• Neurological, cardiovascular and
metabolic impact• diagnosis SGA vs. Late-IUGR
IUGR
SGA?
20 30 4025 35
0
3
3%
CLINICAL PROBLEMS
# 1: DIAGNOSISdetection <50%
# 2: POOR PERINATAL OUTCOME (∼50%)• A “Late-IUGR subset” with poorer perinatal
outcome can be identified
# 3: LONG TERM OUTCOME (∼50%)Fetal programming
No means to select high risk groups
signs adaptation/
severity
yes
no
martes 18 de junio de 13
www.medicinafetalbarcelona.org/
• 5-7% newborns• detection < 50%• > 40% late pregnancy IUFD• Neurological, cardiovascular and
metabolic impact• diagnosis SGA vs. Late-IUGR
IUGR
SGA?
20 30 4025 35
0
3
3%
CLINICAL PROBLEMS
# 1: DIAGNOSISdetection <50%
# 2: POOR PERINATAL OUTCOME (∼50%)• A “Late-IUGR subset” with poorer perinatal
outcome can be identified
# 3: LONG TERM OUTCOME (∼50%)Fetal programming
No means to select high risk groups
poorer
perinatal outcome
normal
signs adaptation/
severity
yes
no
martes 18 de junio de 13
UtA >p95
CPR <p5 EFW CENTILE <3
Prognostic criteria of “poor outcome”-SGACS for distress and/or neonatal acidosis
N=447 SGA + 447 controls
Figueras 2012
martes 18 de junio de 13
UtA >p95
CPR <p5 EFW CENTILE <3
Prognostic criteria of “poor outcome”-SGACS for distress and/or neonatal acidosis
N=447 SGA + 447 controls
Figueras 2012
martes 18 de junio de 13
UtA >p95
CPR <p5 EFW CENTILE <3
0%
10%
20%
30%
40%
50%
Controls All normal Any abnormal
Prognostic criteria of “poor outcome”-SGACS for distress and/or neonatal acidosis
N=447 SGA + 447 controls
Figueras 2012
martes 18 de junio de 13
UtA >p95
CPR <p5 EFW CENTILE <3
0%
10%
20%
30%
40%
50%
8%
Controls All normal Any abnormal
Prognostic criteria of “poor outcome”-SGACS for distress and/or neonatal acidosis
N=447 SGA + 447 controls
Figueras 2012
martes 18 de junio de 13
UtA >p95
CPR <p5 EFW CENTILE <3
0%
10%
20%
30%
40%
50%
8%11%
Controls All normal Any abnormal
Prognostic criteria of “poor outcome”-SGACS for distress and/or neonatal acidosis
N=447 SGA + 447 controls
Figueras 2012
martes 18 de junio de 13
UtA >p95
CPR <p5 EFW CENTILE <3
0%
10%
20%
30%
40%
50%
8%11%
40%
Controls All normal Any abnormal
%
Prognostic criteria of “poor outcome”-SGACS for distress and/or neonatal acidosis
N=447 SGA + 447 controls
Figueras 2012
martes 18 de junio de 13
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Late-onset intrauterine growth restriction vs. small-for-gestational age(submitted)
Figueras 2012
martes 18 de junio de 13
www.medicinafetalbarcelona.org/docencia
Late-onset intrauterine growth restriction vs. small-for-gestational age(submitted)
SGA
40% of late-SGA with 11 % risk (14% of all adverse outcomes)
Figueras 2012
martes 18 de junio de 13
www.medicinafetalbarcelona.org/docencia
Late-onset intrauterine growth restriction vs. small-for-gestational age(submitted)
Late-IUGR
SGA
60% of late-SGA with 40% risk (86% of all adverse outcomes)
40% of late-SGA with 11 % risk (14% of all adverse outcomes)
Figueras 2012
martes 18 de junio de 13
www.medicinafetalbarcelona.org/
1. CIR vs. PEG
2. Precoz vs. Tardío
3. Implicación en el manejo clínico
martes 18 de junio de 13
www.medicinafetalbarcelona.org/
IUGR = abnormal CPR or UtA or EFW<p3
Savchev 2013
martes 18 de junio de 13
www.medicinafetalbarcelona.org/
Protocolo CIR Primer paso: si todo N = PEG
I Doppler normal pero PFE<p3
II Aumento resistencia placentaria o redistribución inicial
III Aumento grave resistencia y/o redistribución grave
IV Alteración hemodinámica grave
V Alto riesgo de muerte
martes 18 de junio de 13
www.medicinafetalbarcelona.org/
Protocolo CIR Primer paso: si todo N = PEG
CPR<p5
Ut A >p95
MCA<p5
I Doppler normal pero PFE<p3
II Aumento resistencia placentaria o redistribución inicial
III Aumento grave resistencia y/o redistribución grave
IV Alteración hemodinámica grave
V Alto riesgo de muerte
martes 18 de junio de 13
www.medicinafetalbarcelona.org/
Protocolo CIR Primer paso: si todo N = PEG
CPR<p5
Ut A >p95
MCA<p5
I Doppler normal pero PFE<p3
II Aumento resistencia placentaria o redistribución inicial
III Aumento grave resistencia y/o redistribución grave
IV Alteración hemodinámica grave
V Alto riesgo de muerte
AEDV AoI >p95
martes 18 de junio de 13
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Protocolo CIR Primer paso: si todo N = PEG
CPR<p5
Ut A >p95
MCA<p5
REDV DV >p95 UVpuls
I Doppler normal pero PFE<p3
II Aumento resistencia placentaria o redistribución inicial
III Aumento grave resistencia y/o redistribución grave
IV Alteración hemodinámica grave
V Alto riesgo de muerte
AEDV AoI >p95
martes 18 de junio de 13
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Protocolo CIR Primer paso: si todo N = PEG
CPR<p5
Ut A >p95
MCA<p5
DV (a rev)
CGT decelerations of reduced short-term
variability
REDV DV >p95 UVpuls
I Doppler normal pero PFE<p3
II Aumento resistencia placentaria o redistribución inicial
III Aumento grave resistencia y/o redistribución grave
IV Alteración hemodinámica grave
V Alto riesgo de muerte
AEDV AoI >p95
martes 18 de junio de 13
Mort. >90% 50% <10%Morb. >90% 50%
www.medicinafetalbarcelona.org/
<26w 26-28 28-32 32-34 34-37
DeliveryDV(a-‐)
cCTG abn.CTG dec.
(a) 28 wDV>p95 / UV puls
(b) 30 wREDV
(a) AEDV(b) AoI>95 CPR>p95
UtA>p95MCA<p5
EFW<p3
Stage V IV III II I
Mode CS CS CS or LI LI
Early-onset IUGRManagement protocol according to severity stages
Follow-‐up Daily 1-‐2 d 2/w 1/w
martes 18 de junio de 13
www.medicinafetalbarcelona.org/
Feto pequeño debe dividirse en: CIR (placenta, mal resultado perinatal y a largo plazo)
PEG (no se sabe, resultado perinatal N, malo a largo plazo)
CIR precoz y tardío (EG 32s) presentan diferencias fisiopatológicas y clínicas marcadas
A nivel clínico, un sólo protocolo integrado permite optimizar decisión en todos los casos
martes 18 de junio de 13
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Prediction of cesarean section for fetal distress after labor induction in term SGA fetuses with Doppler signs of brain sparing (N=202)
Cruz et al, 2010
(OVERALL RISK OF CS AFTER INDUCTION 80 %)
0"
10"
20"
30"
40"
50"
60"
70"
Cesarean"sec1on"for"distress"
Neonatal"acidosis"
AGA"
SGA"normal"MCA"
SGA"abnormal"MCA"
martes 18 de junio de 13