Complexity of Diagnosis in IUGR & Contemporary Pregnancy

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Terry DuBose, MS, RDMS: "This is Terry DuBose in Buenos Aires at the 9th International Congress of the Ultrasound in Obstetrics and Gynecology with Wolfgang Moroder. Dr. Moroder's from Italy, and we've been discussing late pregnancy loss, and I'm going to let him tell you a little bit about his thoughts about the problems we are having with this. Dr. Moroder...?"

Dr. Wolfgang Moroder: "Yes, I like this term, which I actually didn't find in the literature, but opposed to early pregnancy loss, I will call it late pregnancy loss. It's a condition that you have when you go through the different tests that pregnant women do in a very narrow testing setting that we now have mostly all over in Europe and in Italy, like going through the triple test. You find parameters that are altered, and finally you put these women through testing and you find late pregnancy failures. This means that you find these early IUGR's, or early conditions of maternal pregnancy disorders, where they develop early preeclampsia or early health syndromes on one side. On the other side - the fetal side - you find conditions where the placenta is not adequate for the fetal needs. It develops all different patterns of retardation or insufficient nutrition, first showing with early growth retardation. So one of the parameters is the early growth retardation at twenty weeks, when you rule out chromosomal normality. Other parameters are early Doppler anomalies at twenty to twenty-two weeks - we have found an absent end-diastolic flow, a reduced diastolic flow, or even reversed diastolic flow. You look into the venous site of the fetus, you look to the ductus venosus - and you already see abnormal flow patterns in the ductus venosus. You detect abnormal flow patterns in the umbilical vein in the intra-abdominal umbilical vein and in the umbilical vein of the cord. I'm trying to summarize different situations I have heard of recently. As I said, some of these situations arose from the fact that we do triple testing and we find, for example, high HCG values or high AFP values which are not, as I repeat, associated to chromosomal anomalies because those have been ruled out. Another striking feature which I found recently on these early cases of IUGR, or early maladaptive disorders of the fetus to a pregnant uterus, would be an abnormal pattern of the arterial vessels in the fetal abdomen. That's a finding that I guess is quite new, and I haven't found it in the literature yet - you find the fetal mesentery artery or the truncus celiacus artery with a low resistance flow. I really don't know what the meaning of this could be since it's actually contradictive with the brain sparing effect where you hear that the blood flow to the carcass and to the abdomen and to the kidneys, for example, is reduced. In these cases, I've found a low-resistant blood flow in the arteries which I am not yet able to identify, but I think they are the truncus celiacus or the mesentery arteries."

Terry DuBose, MS, RDMS: "That seems to be the dilemma that most of us are facing with sonography now. The equipment in the field has developed so rapidly that we've seen all these problems, and now we have to figure out what to do about them - what do they mean, and what are we seeing? There is a huge number of variables." 

Dr. Wolfgang Moroder: "Right, I think it's a problem. Now the managing of these problems from the obstetrical point of view is determined by the fact that there are so many variables determining these conditions - the maternal variables, the fetal variables, the uterine and the placental variables. You are not able to standardize obstetric conduct; you have to treat every case very singularly. What is most important in your decision making is the consent and the involvement of the pregnant woman, because certain decisions have to be made which are quite dramatic. If you take out a fetus at twenty-four or twenty-five weeks of pregnancy, you know that you expose this fetus to a very hard environment, which is the neonatal intensive care unit. On the other side, you know since you see all these parameters going awry that the baby left inside the uterus is going to die. So you have to make a decision, together with the pregnant woman, as to what you are going to do because it's a dilemma. On both sides there is really extreme danger, and you are sort of going out on a... what do you call it if you go on a mountain?" 

Terry DuBose, MS, RDMS: "Down a narrow path."

Dr. Wolfgang Moroder: "Down a very narrow path, and on each side, if you fall you are going to die."

Terry DuBose, MS, RDMS: "Yes, it's a very difficult dilemma, and I understand you deal with a lot of these cases. You're at a high-risk center?"

Dr. Wolfgang Moroder: "Yes, I work in a high-risk center. We have referrals from seven hospitals with 5,500 deliveries a year, total, from these hospitals. We take all the difficult cases and all the prematures. We do a lot of intrauterine transfer, actually - 95% of the babies below 1,500 grams are transferred to our center from these different hospitals."

Terry DuBose, MS, RDMS: "You've given us an appreciation for the difficulty that we've got to deal with with these things. We're learning so fast, but we have to come to understand what the mechanisms are behind it because we're diagnosing more than we can cure at this time. Thank you, Dr. Moroder."