Klassifikasi IUGR dan

Rekomendasi Menajemen
Berdasarkan Stadium
Dr I Wayan Artana Putra, SpOG(K)

Maternal Fetal Medicine Division, Department of Obstetric and Gynecology

Faculty of Medicine Udayana University / Sanglah General Hospital
2019
 PENDAHULUAN
Definisi
• Small gestational age (SGA) adalah berat janin kurang dari 10th
percentile pada umur tertentu berdasarkan kurve pertumbuhan di
suatu populasi.
• FGR adalah fetus yang kecil dengan risiko tinggi terjadinya
perburukan kondisi bahkan IUFD dan luaran perinatal yang buruk
• FGR dihubungkan dengan gambaran Doppler dari redistribusi
aliran darah yang merupakan adaptasi terhadap nutrisi yang buruk.
hypoxia, tanda histologi dan biokimia kerusakan plasenta.
FAKTOR RISIKO
&
ETIOLOGI
PATHOGENESIS
IUGR
PLACENTAL
DAMAGE
CAUSING IUGR
Klasifikasi IUGR

berdasarkan
gambaran klinis
Klasifikasi IUGR
berdasarkan gambaran klinis
1. Symmetrical IUGR (Hipoplastik kecil masa kehamilan)
• Pembatasan pertumbuhan simetris dimulai pada awal kehamilan
• Jumlah sel berkurang
• Disebabkan oleh faktor intrinsik seperti infeksi bawaan atau kelainan
kromosom
• Bayi dengan hambatan pertumbuhan simetris memiliki pengurangan
semua parameter termasuk berat, panjang dan lingkar kepala.
• Pada kasus seperti itu akan ada perbedaan kurang dari 3 cm antara
kepala dan lingkar dada.
• PI lebih dari 2
2. Asymetrical IUGR (bayi kurang gizi).

• Pertumbuhan abnormal biasanya dimulai pada akhir trimester kedua atau ketiga
• Jumlah sel normal tetapi ukuran sel berkurang
• Pengurangan nutrisi janin yang membatasi glikogen dan penyimpanan lemak,
biasanya disebabkan karena kelainan plasenta.
• Penurunan berat dan panjang terjadi karena efek brain sparing.
• Ciri-ciri kekurangan gizi dikenal dalam bentuk kulit longgar lipat, kehilangan lemak
pinggang, penampakan seperti orang tua
• Indeks Ponderal (PI) kurang dari 2
3. IUGR campuran
• Berkurangnya jumlah sel dan ukuran sel
• Terjadi sebagian besar ketika IUGR onset dini dipengaruhi lebih lanjut oleh
gangguan plasenta di akhir kehamilan
• Memperlihatkann gambaran klinis IUGR baik simetris dan asimetris.
• Bayi dengan jumlah sel normal mempunyi prognosis yang lebih baik dan
pertumbuhan jangka panjang dengan peningkatan perkembangan saraf
(Murki S., 2014)
Klassifikasi Berdasarkan Umur Saat Onset Terjadinya
dan Gambaran Dopller

Early-Onset Fetal Growth Restriction

• Represents 20–30% of all FGRs .
• Association with early PE in up to 50% and highly associated
with severe placental insufficiency and with chronic fetal
hypoxia.
• This explains that UA Doppler is abnormal in a high proportion
of cases
Klasifikasi berdasarkan umur saat onset IUGR dan
gambaran doppler

Late-Onset IUGR
• Late-onset FGR represents 70–80% of IUGR .
• A first distinction with early-onset forms is that the association with late PE is low, roughly
10%.
• The degree of placental disease is mild, thus UA Doppler is normal in virtually all cases.
• Despite normal UA PI Doppler, there is a high association with abnormal CPR values .
• In addition, advanced brain vasodilation suggesting chronic hypoxia, as reflected by an
MCA PI <p5, may occur in 25% of late FGR.
• Advanced signs of fetal deterioration with changes in the DV are virtually never observed
EARLY onset vs LATE onset
IUGR
 TIMELINE FOR FETAL HYPOXIA
ABNORMAL FETAL GROWTH

~ 2 minggu ABNORMAL ARTERIAL DOPPLER

` 1-2 hari ?? ABNORMAL VENOUS DOPPLER

ABNORMAL CARDIOTOCOGRAPH/BPP DOPPLER

DOPPLER CAN PREDICT FETAL DISTRESS SOONER THAN BPP

Deteroriasi Fetus pada early onset IUGR
Doppler Arteri Uterina

• Uterine artery to be useful in predicting

IUGR and preeclampsia.
• A three- to nine-fold increased risk for
IUGR with abnormal second trimester
uterine artery wave forms,
• Some authors have advocated their use for
screening high-risk patients (for IUGR) to
fashion a timeline for surveillance studies.
• Notching – Risk of PE
Doppler Arteri Umbilikalis

• The UAs reflect the richness of the placental (A) Normal umbilical artery at 18 weeks
circulation and often are the first sign of shows relatively high resistance, but
consistent diastolic flow
compromise in early IUGR.
• Absent/reversed end-diastolic flow is a sign of (B) Normal umbilical artery at 36 weeks,
severe placental insufficiency. low resistance, generous diastolic flow.
• Alone, UA results are not an indicator for
interruption of pregnancy, but an increase in
PI will alert the clinician to a placental (C) High resistance, diastolic velocity low.
problem to which fetuses may or may not be
able to adapt.
(D) Absent end-diastolic velocity (AEDV)

(E) Reversed diastolic velocity (REDV) in

severe intrauterine growth restriction
Arteri Cerebri Media
• The MCA reflects a fetal attempt to
adapt to relative hypoxia caused by a
supply line problem. “Brain sparing”
• In IUGR the end-diastolic flow rises,
resulting in a decrease in the S/D
ratio and PI.
• In late IUGR, this may be the only
sign of early fetal compromise and,
even when isolated, has been
associated with later
neurodevelopmental problems.
 Cerebral placental ratio (CPR)

• This simply represents a ratio between the MCA and UA PIs.

• As fetal condition worsens PIs move toward each other, and when
the CPR approaches 1.0, there can be a cause for concern.
• CPRs below the 10th percentile have been associated with higher
rates of emergency cesarean delivery, neonatal morbidity, NICU
admissions, and compromised neonatal acid-base status.
• its value is enhanced when combined with the other tests
Doppler Ductus Venosus
• Shutting down the right lobe of the liver, thus
directing more flow through the DV.
• The oxygenated blood encounters more
competition for entry into the right atrium.
• The waveform gradually will show a decrease
in flow during atrial contraction (reflected by
the a wave
• When the a wave approaches zero, or dips
below it, the fetus is in a pre-demise state.
Aortic Isthmus Doppler

• This vessel reflects the balance between

the impedance of the brain and systemic
vascular systems .
• Reverse AoI flow is a sign of advanced
deterioration and a further step in the
sequence starting with the UA and MCA
Dopplers .
• Remarkably, the AoI can be found
abnormal also in a small proportion of
late-onset FGRs
Staging of Intrauterine Growth-Restricted Fetuses based on
Fetal Biometry, Doppler Cardiovascular Changes, Amniotic
Fluid Volume and Clinical Parameters

Mari et al
Francesc Figueras Eduard Gratacós, 2014
Stage I Fetal Growth Restriction
(Severe Smallness or Mild Placental Insufficiency)

• Either UtA, UA or MCA Doppler, or the CPR are abnormal. In the absence
of other abnormalities, evidence suggests a low risk of fetal deterioration
before term.
• Labor induction beyond 37 weeks is acceptable, but the risk of
intrapartum fetal distress is increased .
• Cervical induction with Foley catheter is also recommended. Weekly
monitoring seems reasonable.
Stage II Fetal Growth Restriction
(Severe Placental Insufficiency)

• This stage is defined by UA absent-end diastolic velocity (AEDV) or reverse AoI.

Although evidence for UA AEDV is stronger than that for AoI, observational
evidence suggests an association between the latter to abnormal
neurodevelopment, so that both criteria become a single category.
• Delivery should be recommended after 34 weeks.
• The risk of emergent cesarean section at labor induction exceeds 50%, and,
therefore, elective caesarean section is a reasonable option.
• Monitoring twice a week is recommended.
Stage III Fetal Growth Restriction
(Advanced Fetal Deterioration, Low-Suspicion Signs of Fetal Acidosis)

• The stage is defined by reverse absent-end diastolic velocity (REDV) or DV PI

>95th centile.
• There is an association with a higher risk of stillbirth and poorer neurological
outcome.
• Delivery should be recommended by cesarean section after 30 weeks.
• Monitoring every 24–48 h is recommended.
Stage IV Fetal Growth Restriction
(High Suspicion ofFetal Acidosis and High Risk of Fetal Death)
• There are spontaneous FHR decelerations, reduced STV (<3 ms) in the cCTG, or reverse
atrial flow in the DV Doppler.
• Spontaneous FHR deceleration is an ominous sign, normally preceded by the other two
signs, and thus it is rarely observed, but if persistent it may justify emergency caesarean
section.
• CTG and DV are associated with very high risks of stillbirth within the next 3–7 days and
disability..
• Intact survival exceeds 50% only after 26–28 weeks, and before this threshold parents
should be counseled by multidisciplinary teams.
• Monitoring every 12–24 h until delivery is recommended.
 Stage-
based deci
sion
algo
rithm
for the
mana
Gement
of
FGR

Francesc Figueras Eduard Gratacós, 2014

MATUR SUKSMA