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Case 182

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Patient, 32 years old, fourth pregnancy with three previous abortions, without comorbidities or complaints. Seeks obstetric evaluation due to history of multiple miscarriages, in which genetic studies have shown fetuses with normal karyotypes. Gestational age of 36 weeks, blood group A, Rh negative, BMI = 22, normoglycemic, susceptible to toxoplasmosis and unmarkable serology. On examination: blood pressure = 120x70mmHg, uterus fundus of 24cm, uterus’ cervix was posterior, long and closed. Results from previous obstetrical ultrasound (Table 1).

Based on clinical history, laboratory tests, ultrasound and Doppler velocimetric evolution, which is the most likely diagnosis and the best therapeutic management?

a) Fetus small-for-gestational-age; ultrasound monitoring is indicated until the end of term.

25%

b) Fetus with intrauterine growth restriction (IUGR), type I - Symmetrical; absolute rest and follow up to the end of term are indicated.

25%

c) Fetus with intrauterine growth restriction (IUGR), type II - Asymetrical; immediate cesarean section is indicated.

25%

d) Fetus with intrauterine growth restriction (IUGR), intermediate type; administration of dexamethasone (2 doses of 12 mg, IM, at 24 intervals) is indicated.

25%
   

Image analysis

Image 1: Doppler velocimetry of the middle cerebral artery at gestational age of 36 weeks demonstrating zero diastole (red arrow) which, together with the reversal of the umbilical-cerebral ratio, are predictors of adverse perinatal outcome.

Highlights

- In Type I IUGR, or symmetrical, the aggressor reaches the fetus in the early stage of development leaving it proportionally small, and the primary causes are maternal-fetal infections.

- In Type II IUGR reduction in waist circumference predominates when compared to the cephalic circumference, and it is linked to placental insufficiency.

- For the diagnosis of IUGR, the correct gestational age is essential and ultrasound is the imaging method of choice.

- The symmetrical IUGR is the worst prognostic group, with high rates of perinatal mortality and of neurological sequelae.

- In asymmetrical IUGR, the management is usually expectant in the absence of fetal maturation and when this is reached, the delivery is done.

References

- Rizzo G, Arduini D. Intrauterine growth restriction: diagnosis and management - A review. Minerva Ginecol 2009;61(5):411-20.

- Lausman A, McCarthy F, Walker M, Kingdom J. Screening, Diagnosis, and Management of Intrauterine Growth Restriction. J Obstet Gynaecol Can 2012;34(1):17–28

- Nomura RMY, Miyadahira S, Zugaib M. Avaliação da vitalidade fetal anteparto. Ver Bras Ginecol Obstet 2009;31(10):513-26,

- Moreira de Sá RA, Oliveira CA, Peixoto-Filho FM, Lopes LM. Predição e prevenção do crescimento intrauterino restrito. Femina 2009;37(9):511-514.

- Melo ASO, Assunção PL, Amorim MMR, Cardoso MAA. Determinantes do crescimento fetal e sua repercussão sobre o peso ao nascer. Femina 2008;36(11):683-689.

- Francisco RPV, Nomura RMY, Miyadahira S, Zugaib M. Diástole zero ou reversa à dopplervelocimetria das artérias umbilicais. Rev Assoc Med Bras 2001;47(1):30-36.

- Santos AMM, Thomaz ACP, Rocha JES. Crescimento intra-uterino restrito diagnosticado pelo índice ponderal de Rohrer e sua associação com morbidade e mortalidade neonatal precoce. Rev Bras Ginecol Obstet 2005;27(6):303-309.

Authors

Bárbara de Queiroz e Bragaglia, 5th year medical student at UFMG. E-mail: barbara.bragaglia[at]gmail.com.

Renato Gomes Campanati, residente of general surgery at Hospital das Clínicas - UFMG. E-mail: campanati[at]ufmg.br.

Supervisors

Cláudia Ramos de Carvalho Ferreira, professor at the gynecology and obstetrics department of the Faculdade de Medicina da UFMG. E-mail: claudia[at]ufmg.br

 

Roseli Mieko Yamamoto Nomura, professor at the gynecology and obstetrics department of the Faculdade de Medicina da Universidade de São Paulo. E-mail: roseli.nomura[at]hotmail.com

Reviewers

Marina Leão, André Guimarães, Ana Luiza Mattos, Letícia Horta and prof. Viviane Santuarini Parisotto. 

Acknowledgements

To Dr. Roseli Nomura for her availability and attention.

Translated by

Bárbara de Queiroz e Bragaglia, 5th year medical student at UFMG. E-mail: barbara.bragaglia[at]gmail.com

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