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    Antenatal Assessment of Fetal Wellbeing

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    This document discusses various methods for assessing fetal well-being during pregnancy, including: 1. Monitoring fetal movements and measuring symphysio-fundal height to screen for potential issues. 2. Using specific tests like cardiotocography (CTG), ultrasound, biophysical profile (BPP), and Doppler ultrasound to more directly evaluate the fetus. These tests analyze factors like the fetal heart rate, breathing movements, tone, amniotic fluid volume, and blood flow in key vessels. 3. Interpreting results from CTG, BPP, and Doppler ultrasound to identify signs of fetal hypoxia or stress that could indicate the need for timely medical intervention to prevent injury or death. None of

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    Antenatal Assessment of Fetal Wellbeing

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    This document discusses various methods for assessing fetal well-being during pregnancy, including: 1. Monitoring fetal movements and measuring symphysio-fundal height to screen for potential issues. 2. Using specific tests like cardiotocography (CTG), ultrasound, biophysical profile (BPP), and Doppler ultrasound to more directly evaluate the fetus. These tests analyze factors like the fetal heart rate, breathing movements, tone, amniotic fluid volume, and blood flow in key vessels. 3. Interpreting results from CTG, BPP, and Doppler ultrasound to identify signs of fetal hypoxia or stress that could indicate the need for timely medical intervention to prevent injury or death. None of

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    This document discusses various methods for assessing fetal well-being during pregnancy, including: 1. Monitoring fetal movements and measuring symphysio-fundal height to screen for potential issues. 2. Using specific tests like cardiotocography (CTG), ultrasound, biophysical profile (BPP), and Doppler ultrasound to more directly evaluate the fetus. These tests analyze factors like the fetal heart rate, breathing movements, tone, amniotic fluid volume, and blood flow in key vessels. 3. Interpreting results from CTG, BPP, and Doppler ultrasound to identify signs of fetal hypoxia or stress that could indicate the need for timely medical intervention to prevent injury or death. None of

    Copyright:

    © All Rights Reserved
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    Download as pdf or txt
    85 views52 pages

    Antenatal Assessment of Fetal Wellbeing

    Uploaded by

    6ixSideCreate M
    This document discusses various methods for assessing fetal well-being during pregnancy, including: 1. Monitoring fetal movements and measuring symphysio-fundal height to screen for potential issues. 2. Using specific tests like cardiotocography (CTG), ultrasound, biophysical profile (BPP), and Doppler ultrasound to more directly evaluate the fetus. These tests analyze factors like the fetal heart rate, breathing movements, tone, amniotic fluid volume, and blood flow in key vessels. 3. Interpreting results from CTG, BPP, and Doppler ultrasound to identify signs of fetal hypoxia or stress that could indicate the need for timely medical intervention to prevent injury or death. None of

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    Antenatal Assessment of

    Fetal Wellbeing

    Dr Aisha Sarfraz
    Senior Registrar Obs & Gynae
    Civil Hospital, Bahawalpur, Pakistan
    ANTENATAL ASSESSMENT OF
    FETAL WELL BEING

    Prenatal care is designed to ensure


    the well being of both the expectant
    mother and the fetus
    AIMS

    • To identify fetuses at risk of intrauterine


    hypoxia so that a permanent injury or
    death can be prevented by timely
    intervention.
    • To identify healthy fetuses among those
    suspected to be in problem on clinical
    evaluation so that an unnecessary
    intervention may be avoided.
    Who?
    • Conditions placing the fetus at risk for UPI
    – Preeclampsia, chronic hypertension,
    – Collagen vascular disease, diabetes
    mellitus, renal disease,
    – Fetal or maternal anemia, blood group
    sensitization,
    – Hyperthyroidism, thrombophilia, cyanotic
    heart disease,
    – Postdate pregnancy,
    – Fetal growth restriction
    IDEAL TEST
    • allows intervention before fetal death or damage
    from asphyxia.
    • Which has lower false positive and false negative
    rates.
    • FN antenatal test: incidence of fetal death within
    one week of a normal ante partum test.
    • FP test: abnormal test that prompts untimely
    delivery but is not a/e evidence of fetal
    compromise (meconium stained amniotic fluid,
    intrapartum fetal distress, low A/S and IUGR)
    None of currently available tests fulfill this criteria
    and reported FNr ranges from 0.4 to 1.9/1000 and
    FPr from 30-90 %.

    TIMINGS OF PRENATAL
    ASSESMENT

    Later half of pregnancy

    • after the age of viability


    • 1st Trimester: USG
    • 2nd Trimester: Biochemical test
    TESTS(2nd half of pregnancy)

    1- Screening Tests
    • Fetal movements
    • Symphysio fundal height

    2 - Specific tests
    • CTG
    • USG
    • BPP
    • Doppler USG
    Fetal movement counting
    • In presence of uteroplacental insufficiency
    FM decrease for several days and stop
    approx 24-48 hrs prior to fetal demise
    (attempt to save oxygen for more vital
    functions)
    • Cardiff “count to ten” : 10 movements in 12
    hours.
    • Kick charts
    • Counting FM 2-3 times daily for 30 min
    (further evaluation if <4 strong movements
    in 30 min
    Advantages
    • Cheap, Continuous observation, Maternal
    involvement, reported to perinatal mortality

    Disadvantages
    • Rest activity behavior of fetus( maternal anxiety,
    frequency of hospital admission, use of CTG &
    C/S)
    • Naturally quite fetus may take long time before 10
    movements are registered.
    • Still births continue to occur with patients failing to
    report absence of noticeable FM.
    Symphysiofundal height
    • Serial measurements are more effective than
    single.
    • SFH measurement after 24 wks has been taken
    to be equal in cms to the week of gestation
    +2cm to 36 wks, and 3cms from 36-42 wks.
    • Reduced SFH measurements correctly identify
    only 25-50% of fetuses whose birth weight was
    <10th centile.
    Specific tests
    1. CARDIOTOCOGRAPHY
    (non stress test)
    Antenatal CTG employs external(indirect methods
    of monitoring of fetal heart rate).
    3 techniques:
    a. Phonocardiography,
    b. fetal ECG,
    c. Ultrasound fetal CTG : Record of fetal cardiac
    & uterine behavior on a paper is cardiotocograph
    and procedure is called cardiotocography.
    INTERPRETATION
    In antepartum CTG the study of uterine behavior has
    little use only records Braxton hicks contractions.
    Four variables of CTG:
     Baseline FHR
     FHR variability
     Acceleration
     Deceleration
    All 4 variables are affected by oxygen deficiency,
    making it a useful tool for diagnosis of antepartum
    fetal hypoxia. Fetal cardiac activity is controlled by
    both sympathetic & parasympathetic nervous system
    which accelerates and lowers it respectively.
    The fetal nervous system matures between 28-32 wks
    • Before 28 wks CTG is relatively featureless & has high
    baseline FHR & reduced variability. With advancing
    gestation FHR slows down & variability increases.
    • After 28 wks fetus develops cycles of quiet – active
    sleep lasting for 60-70 min. Quiet sleep phase usually
    lasts for 20-30 min & characterized by absence of fetal
    movements & CTG exhibits absence of accelerations
    and low FHR variability.

    CTG VARIABLES

    a. BASELINE FHR :
    In late pregnancy b/w 110-150 bpm
    Effects of hypoxia:
    Acute hypoxia stimulates carotid artery CRs
    stimulates ANS via carotid sinus nerve
    Parasympathetic fetal bradycardia
    Sympathetic peripheral vasoconstriction &
    redistribution of cardiac output to brain, heart &
    adrenals.
    Prolonged hypoxemia secretion of
    catecholamines BP & FHR overcomes vagal
    bradycardia & baseline FHR is restored but
    vasoconstriction is maintained.
    once oxygen delivery returns to normal vagal
    tone returns to normal unopposed catecholamines
    rebound tachycardia. CAs Normal heart rate
    Chronic Hypoxia: constant rise in CAs maintains FHR
    within normal limits by counteracting chronic vagal
    stimulation, the peripheral vasoconstriction is also
    maintained. Variability & acceleration also returns to
    normal if chronic hypoxemia is not severe enough to
    result in acidemia. Any acute insult over chronic hypoxia
    manifest as change in variability.
    BRADYCARDIA(non hypoxic) Prolonged
    pregnancy,
    fetal heart block, maternal hypothyroidism, SLE, CMV
    hypoglycemia, hypothermia, b-blockers, local
    anesthetics
    Idiopathic.
    TACHYCARDIA(non hypoxic) fetal prematurity,
    b. FHR VARIABILITY :
    Short Term Beat To Beat Variability: variation of heart
    rate in successive beats.
    Long Term Variability: 5-25bpm. Reduced during
    hypoxia and quiet –sleep phase of baby, prematurity,
    maternal drugs like pethidine,diazepam & local
    anesthetics.
    Reduced variability with decelerations should be taken
    seriously.
    It should be differentiated from sinusoidal FHR
    pattern(sign wave of fixed periodicity of 2-5 cycles/min,
    Amplitude of >25 bpm with loss of short term variability.
    Seen in fetal anemia, fetal sickling.
    c. Acceleration: Increase in FHR of >15bpm which
    persists for >15sec associated with fetal movements,
    external stimuli or uterine contractures.
    Loss of accelerations is usually first sign of hypoxia but
    also absent in quite sleep phase of fetus.
    d. Deceleration:
    A drop in FHR of >15bpm which persists for 10sec or
    more.
    It’s a sign of hypoxia but also associated with maternal
    supine hypotension syndrome. An isolated deceleration
    when transient has little clinical significance while
    recurrent decelerations specially in absence of uterine
    activity & with loss of beat to beat variability is sign of
    poor prognosis.
    REACTIVE CTG:
    1- Baseline FHR 110-150,
    2- variability 5-25bpm,
    3- 2 accelerations
    4- No decelerations in 15-20min

    SEQUENCE OF EVENTS IN HYPOXIA:


    Absence of acceleration Loss of beat to beat
    variability appearance of decelerations.

    STRESS TEST:
    1- Oxytocin challenge test
    2- Nipple stimulation test
    3- Vibroacoustic stimulation
    Baseline tachycardia
    Baseline bradycardia
    normal beat to beat variability
    Poor or absent variability
    normal FHR accelerations with uterine
    contractions
    Decelerations
    • Decelerations-
    transient slowing of
    FHR below the
    baseline level of
    more than 15 bpm
    and lasting for 15 s
    or more
    Antenatal CTG

    • Perinatal mortality: 6.2/1000


    • False positive rate: 50%
    • False negative rate: 3.2 / 1000
    2- ULTRASOUND
    • Quick, non-invasive procedure, easy
    interpretation
    • Customised fetal growth charts (serial scans)
    • Liquor volume
    • Placental function
    – Doppler study
    • Abnormal results correlate with increased risk
    of stillbirth and neonatal morbidity in selected
    pregnancies
    3- BIOPHYSICAL PROFILE

    • Described by Manning (1980)


    • The number of biophysical activities that
    could be recorded increased with real time
    ultrasound:
    – Fetal movement (FM)
    – Fetal tone (FT)
    – Fetal breathing movements (FB)
    – Amniotic fluid volume (AFV)
    Variables measured
    • CTG: reactive – as described earlier.
    • FBM: present - at least 1 episode of at
    least 60 seconds duration (within a 30min
    period).
    • FM: present - at least 3 discrete episodes.
    • FT: normal - at least 1 episode of
    extension of extremities or spine with return
    to flexion.
    • AFV: normal – largest pocket of fluid
    greater than 1 cm in vertical diameter.
    Scoring

    • Biophysical profile (BPP)


    – Each variable
    • When normal: 2
    • When abnormal: 0
    – Highest Score: 10, Lowest Score: 0
    – Accuracy improved by increasing the
    number of variables assessed.
    – Overall false negative rate: 0.6/1000
    SEQUENCE OF EVENTS IN HYPOXIA
    • Non-reactive CTG
    • Absence of fetal breathing movement
    • Reduction or loss of FM
    • Loss of fetal tone

    MODIFICATION
    • CTG with AFV & FBM
    • CTG with AFV
    4- DOPPLER ULTRASOUND

    – Four fetal vessels


    Umbilical & middle cerebral artery
    Thoracic aorta & ductus venosus

    – In high risk pregnancies umbilical artery


    doppler improves perinatal outcome.
    Doppler velocimetry

    • Uterine arteries – 24/40


    UMBILICAL ARTERIAL DOPPLER

    • Mid portion of cord


    • In fetal quiescence
    • Use RI or PI
    • Progressive fall in resistive indices
    throughout normal pregnancy
    • Angle, sample volume important
    • Extremes of fetal heart rate will affect result
    S = peak systolic frequencies D = least diastolic frequencies
    S-D/S = resistance or Pourcelot index
    S-D/mean = Pulsatility index
    (S/D = s d ratio, cannot describe AEDV )
    These are gestation dependent the trend is important
    NORMAL INDICES
    • PI (S-D/mean) 0.8 – 1.1
    • RI(S-D/S) at 30wks 0.8 – 0.98
    at 35wks 0.75 – 0.95
    at 40wks 0.70 – 0.90
    • S/D ratio at 20wks 4.0
    at 30wks 3.0
    at 40wks 2.0
    PI is preferred theoretically since it can still quantify
    FVW in the absence of diastolic flow.
    Clinically S/D ratio is commonly used while waveforms
    with absent or reverse EDF are classified separately.
    Use of Umbilical Arterial Doppler in
    high risk pregnancy
    (preeclampsia and SGA)
    • 30% reduction in perinatal death
    • 40% reduction in admissions
    ∀↑ deliveries< 34 weeks
    • No differences in C/S or fetal distress
    in labour

    Cochrane review2000
    Fetal growth restriction

    Fetal “overgrowth”
    Umbilical Doppler
    FETAL VENOUS
    DOPPLER
    • Venous Doppler
    a marker of fetal cardiac dysfunction
    influenced by fetal behavioural state esp FBM
    • Umbilical vein non pulsatile
    pulsatile decreased forward flow at end diastole
    • Ductus Venosus “M” shaped waveform
    reversed velocities abnormal
    proposed uses TTTS
    aneuploidy screening 1st T
    anaemia
    FETAL DOPPLER SUMMARY

    • Umbilical artery well assessed


    • Trend through gestation important
    • Absent end diastolic velocities or reversed
    velocites always abnormal
    • Doppler does not tell when delivery should
    occur
    • Later in gestation fetus less tolerant of
    abnormal Doppler
    • Pulsatile umbilical vein may be preterminal
    Uterine artery
    assessment
    UTERINE ARTERY FLOW VELOCITY
    WAVEFORMS
    Upper panel normal waveform
    Lower panel abnormal with notching
    IUGR Sequence
    AFI & UA Doppler changes

    MCA changes

    Venous doppler changes

    Reduction in short term variability (on comp CTG) &


    spontaneous decelerations on routine CTG

    Abnormal BPP ( breathing movements)


    CONCLUSION
    Abnormal screening test
    Scan for growth measurements

    Within normal range & small measurement


    No risk factors for UPI
    doppler studies
    Reassurance & surveillance
    With FM & SFM Normal Abnormal
    (UPI excluded)

    SGA Admission
    monitoring with CTG
    Growth scan & BPP
    THANK YOU

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