Publication: Crecimiento intrauterino restringido tardío: optimización del diagnóstico y tratamiento
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2020-01-15
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Universidad Complutense de Madrid
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Abstract
El crecimiento intrauterino restringido (CIR) constituye una entidad en la que el feto no alcanza su potencial intrínseco de crecimiento1. Si bien puede deberse a cromosomopatías (5-20%), infecciones congénitas (5-10%) o malformaciones (1-2%), el CIR en más de dos terceras partes de los casos es el resultado de un desajuste entre el aporte placentario y las necesidades nutricionales fetales2,3. Es el denominado CIR de causa placentaria (CIRp).El CIRp tardío (aquel diagnosticado a partir de la semana 32), afecta a un 3-5% de todos los embarazos4 y se asocia a un mayor riesgo de morbilidad perinatal y mortalidad, así como comorbilidades a largo plazo tanto a nivel de desarrollo neurológico, como cardiovascular o metabólico5. Su correcta identificación y evaluación son claves para un manejo adecuado, resultando además fundamental diferenciar a aquellos fetos constitucionalmente pequeños de los que realmente tienen un CIRp, ya que su evolución y pronóstico serán distintos. Para ello se han identificado una serie de marcadores prenatales ecográficos, como la estimación del peso fetal o la evaluación de la hemodinámica materno-fetal mediante el estudio Doppler. En el caso de los primeros, el estudio hemodinámico será normal y el pronóstico bueno, con una adecuada tolerancia al parto. En el de los segundos, el peso fetal estimado (PFE) se sitúa por debajo del percentil (p) 3 o bien, sin llegar a caer hasta percentiles tan bajos, aparecen alteraciones hemodinámicas y el pronóstico, aunque favorable, será algo peor, con aumento de la mortalidad intrauterina a partir de la semana 37-386, menor tolerancia al parto y peor evolución posnatal7...
Fetal growth restriction (FGR) refers to a situation in which a fetus is not able to fully reach its growth potential1. Although it can be the result of chromosomal anomalies (5-20%), congenital infection (5-10%) or other major malformations (1-2%), more than two thirds of IUGR cases are caused by a mismatch between placental supply and the fetuses’ nutritional demands2,3. This is the so called placental-related fetal growth restriction (pFGR)Late-onset pFGR (diagnosed after 32 weeks), affects 3-5% of all pregnancies4 and is associated to higher rates of perinatal morbidity and mortality, as well as long term neurological, cardiovascular or metabolic comorbidities5. Their correct diagnosis and evaluation are key for an appropriate management as well as for differentiating them from constitutionally small fetuses, given that their evolution and prognosis will be different. In order to differentiate these entities, a series of sonographic prenatal markers have been identified such as the estimation of fetal weight or the evaluation of maternal-fetal hemodynamics through Doppler study. In the case of the constitutionally small fetuses, the hemodynamic study will be normal and the prognosis good, with an adequate fetal tolerance to labor. In FGR, the estimated fetal weight (EFW) will be below the third centile or, in cases where it is not as extremely low (<10th centile), it will be accompanied by slight hemodynamic alterations and prognosis, although favorable, will be somewhat worse, with an increase in stillbirth from 37-38 weeks5, lower tolerance to labor and worse postnatal development6...
Fetal growth restriction (FGR) refers to a situation in which a fetus is not able to fully reach its growth potential1. Although it can be the result of chromosomal anomalies (5-20%), congenital infection (5-10%) or other major malformations (1-2%), more than two thirds of IUGR cases are caused by a mismatch between placental supply and the fetuses’ nutritional demands2,3. This is the so called placental-related fetal growth restriction (pFGR)Late-onset pFGR (diagnosed after 32 weeks), affects 3-5% of all pregnancies4 and is associated to higher rates of perinatal morbidity and mortality, as well as long term neurological, cardiovascular or metabolic comorbidities5. Their correct diagnosis and evaluation are key for an appropriate management as well as for differentiating them from constitutionally small fetuses, given that their evolution and prognosis will be different. In order to differentiate these entities, a series of sonographic prenatal markers have been identified such as the estimation of fetal weight or the evaluation of maternal-fetal hemodynamics through Doppler study. In the case of the constitutionally small fetuses, the hemodynamic study will be normal and the prognosis good, with an adequate fetal tolerance to labor. In FGR, the estimated fetal weight (EFW) will be below the third centile or, in cases where it is not as extremely low (<10th centile), it will be accompanied by slight hemodynamic alterations and prognosis, although favorable, will be somewhat worse, with an increase in stillbirth from 37-38 weeks5, lower tolerance to labor and worse postnatal development6...
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Tesis inédita de la Universidad Complutense de Madrid, Facultad de Medicina, Departamento de Osbtetricia y Ginecología, leída el 22-05-2019