FETAL WELLBEING

DEFINITION Fetal well being means healthy fetus. In Fetal well being normal growth and development as well as its normal activity and viability is checked. Now a days antenatal care is given to antenatal mothers and there are tests that provide information and reassurance to mothers regarding well being of the fetus e.g. fetal movements count. It elicits information about recent fetal movements to reassure the mother. Patterns of fetal movements are reliable sign of fetal well being. PURPOSES OF ANTENATAL FETAL MONITORING: 1. Assuring satisfactory growth and well being of the fetus as well as the mother all throughout the pregnancy. !. "creening out high risk cases and the adverse maternal and intrauterine factors which may affect the healthy growth of the fetus. #. $etecting early in pregnancy those congenital abnormalities or inborn metabolic disorders which are not compatible with life or may lead to chronic ill health of the offspring. %hese may be eliminated by early termination of pregnancy. FETAL WELL BEING TESTS: For monitoring fetal well being many tests are there which can be broadly classified as& I. 'io Physical %ests 1. 'io Physical Profile ('PP) 2. *ltrasonography 3. +"% 4. $aily fetal movement count ($F,+) 5. Internal heart rate monitoring 6. -adiological e.ams II. 'iochemical %ests 1. ,aternal 2. Fetal 3. Placental III. +ytogenic %ests 1. +/" 2. +ordocentesis 3. Amniocentesis I/. ,aternal Assay I. BIO- PHYSICAL TESTS

1. BIOPHYSICAL PROFILE (BPP :%he biophysical profile ('PP) is a test performed to measure fetal well being. It is a prenatal evaluation of fetal wellbeing0 involving a scoring system. It includes four ultrasounds and one N"%. A 'PP is commonly done in the last trimester of pregnancy. If there is a chance that baby may have problems during pregnancy (high risk pregnancy)0 a 'PP may be done by #! to #1 weeks or earlier. "ome women with high risk pregnancies may have a 'PP test every week or twice a week in the third trimester. %he biophysical profile ('PP) has 2 components& 1. fetal breathing !. fetal body movement #. fetal muscle tone 1. fetal reactivity 2. amniotic fluid inde. F!"#$ %&!#"'()* (FB is measured by watching for movement of the fetal thora. and diaphragm. %his is to assure breathing0 and not 3ust chest wall movement. It is done by *ltrasound. F!"#$ %+,- .+/!.!)" is defined by gross arm0 leg0 or body activity. A score of two is given if there are at least three separate limb4body movements during the #5 minute test. It is done by ultrasound0 $F,+ F!"#$ .012$! "+)! is defined by active e.tension and fle.ion of the fetal limbs0 trunk0 or hand6 or if the hand remains in a fle.ed position during the entire #5 minute test. It is also done by *ltrasound. F!"#$ R!#2"(/("-: heart rate (F7-) variability is measured during fetal reactivity. %he fetal heart rate is normally variable in nature. Accelerations in F7- are usually seen in response to fetal movements and are therefore reassuring. ,easuring F7- has two different methods. 8.ternal heart rate monitoring

by using fetoscope stethoscope $oppler *"9 Internal heart rate monitoring i.e from fetal scalp

F7- variability can be measured by two methods i.e. N"% and +"%. A.)(+"(2 3$0(, volume is estimated for sufficiency. "ince fetal anatomic structures do not allow full visuali:ation of all the amniotic fluid0 it is estimated by measuring pockets of fluid from 5.#; to 5.<= in (1 to ! cm) in height on ultrasound. A score of two is given if at least one pocket of fluid measures 5.<= in (! cm) or more in height. A score of :ero is given when no such pockets can be measured. Normal amniotic fluid volume peaks at about <25 ml at #! weeks gestation0 stays stable until term at 15 weeks0 and then declines to about 155 ml by 1! weeks. 8.cessive amniotic fluid amounts (hydramnios)0 such as might be seen in diabetic mothers0 may be as high as 1<55 to 1;55 ml. >ligohydramnios is defined by about #55 ml of fluid volume. %he amniotic fluid is produced as the fetus urinates and through lung secretions. %he volume is controlled by fetal swallowing and by reabsorption through the membranes. %he amniotic fluid inde. (AFI) is also used to determine sufficiency of amniotic fluid. In this method0 the largest vertical column of fluid in each of the four uterine ?uadrants is measured and added up. Normal AFI value is between 2 to !2. 'ecause of the role of the fetus in the production and control of amniotic fluid0 it is one variable in fetal wellbeing assessment. P0&4+1!1 A biophysical profile ('PP) test is done to& 1. @earn about and keep track of fetal wellbeing. "pecial ultrasound methods are used to keep track of movement0 increase in heart rate with movement (nonstress test)0 muscle tone0 breathing rate0 and the amount of amniotic fluid surrounding your baby. If these five areas are within a normal range0 your baby is considered to be in good health. !. It is a tool used near or at term by clinicians to assess the potential risk of fetal compromise or demise due to fetal hypo.ia or acidosis. Intervention such as maternal hospitali:ation or delivery may follow a 'PP score of four or below. #. It keep check on babyAs health in case of&

7yperthyroidism. 'leeding problems. @upus. +hronic kidney disease. %ype 1 diabetes or gestational diabetes. 7igh blood pressure (hypertension). Preeclampsia. A small amount of amniotic fluid (oligohydramnios) or too much amniotic fluid (polyhydramnios). A multiple pregnancy (such as twins or triplets). A pregnancy that has gone past your due date0 between 15 and 1! weeks.

P&!4#&#"(+)

*sually a full bladder is needed for the test. If so0 client is asked to drink water or other li?uids 3ust before the test and to avoid urinating before or during the test. If client smoke0 she is asked to stop smoking for ! hours before the e.ternal monitoring test because smoking decreases babyAs activity. 'ecause the 'PP is done during the third trimester of pregnancy0 there is sufficient amniotic fluid to provide contrast to clearly visuali:e the fetus. No preparation is usually re?uired before the test is performed. %he mother may be asked to have a snack prior to the test to encourage a more active fetus. 'ecause the motherAs abdomen is e.posed0 curtains or a closed door should provide privacy. A comfortable room air temperature and the warming of the transducer gel can assist in putting the mother at ease.

%he mother should be asked if she wants her partner or support person with her during the test. A towel or cloth should cover the motherAs clothing to avoid its getting wet from the transducer gel. For a transvaginal fetal ultrasound0 the vaginal transducer is usually covered with a late. sleeve and a vaginal lubricant0 such as B C Delly. If you are allergic to late.0 tell the health professional before having the test.

P&+2!,0&! ,ost often0 a biophysical profile ('PP) is performed by obstetrician. 'ut it may be done by an ultrasound technologist or radiologist. A 'PP can be done in doctorAs office0 hospital0 or clinic. N+)1"&!11 "!1" A nonstress test with electronic fetal heart monitoring and a fetal ultrasound are done as part of a biophysical profile. 8.ternal fetal heart monitoring records babyAs heart rate while baby is moving and not moving. It is usually done 3ust before a fetal ultrasound. %his test can be done in the later stages of pregnancy. It is more fre?uently used in cases where the mother is going past her assigned due date to ensure fetal well being. In some cases it is done as a precaution after problems in a previous pregnancy or because of high risk factors such as diabetes0 intrauterine growth retardation (I*9-)0 etc. 8.ternal monitoring is done using two flat devices (sensors) held in place with elastic belts on your belly. >ne of these uses reflected sound waves (ultrasound) to keep track of your babyAs heart rate6 the other measures the duration of your contractions. %he sensors are connected to a machine that records the information. 'abyAs heartbeat may be heard as a beeping sound or printed out on a chart. If baby moves or mother have a contraction0 she may be asked to push a button on the machine. 'abyAs heart rate is recorded and compared to the record of movement or mothers contractions. %his test usually lasts about #5 minutes. "ometimes little ones donAt cooperate during the testing and move. "o the mother is offered a drink of something usually containing sugar or bubbles to perk the baby up. If this doesnAt cause the baby to move sometimes a loud sound will be used to startle the baby into moving. -emember babies can and do sleep in utero.

P&+2!,0&! +3 U$"&#1+)+*&#4' ,other may need to have a full bladder. "he may be asked to drink 1 to E glasses of li?uid0 usually 3uice or water0 about an hour before the test. A full bladder helps transmit sound waves and pushes the intestines out of the way of the uterus. %his makes the ultrasound picture clearer. "he will not be able to urinate until the test is over. 'ut the ultrasound technologist can be informed if bladder is so full that she is in pain. If an ultrasound is done during the later part of pregnancy0 a full bladder may not be needed. %he growing fetus will push the intestines out of the way. @ay the client on her back on a padded e.amination table. If she become short of breath or lightheaded while lying on your back0 her upper body may be raised or she may be turned on side. >ften she do not need to remove her clothes for the ultrasound test6 but shirt can be lift up and the waistband of skirt or pants can be pushed down. If she is wearing a dress0 a cloth is given to cover during the test. A gel is spread on abdomen. A small0 handheld instrument called a transducer will be pressed against the gel on skin and moved across the abdomen several times. +lient may watch the monitor to see the picture of the fetus during the test. @ying on the back (or side) during the test may be uncomfortable. $uring a fetal ultrasound0 client may have a feeling of pressure in bladder. %he gel may feel cool when it is first applied to abdomen. A light pressure from the transducer is felt as it passes over your abdomen. Fhen the test is finished0 the gel is cleaned off. +lient can urinate as soon as the test is done. %ransabdominal ultrasound takes about #5 to E5 minutes. *ltrasound technologists are trained to gather images of fetus but cannot tell whether it looks normal or not. -adiologist or perinatologist can give this information after the ultrasound images have been reviewed. T&#)1/#*()#$ 0$"&#1+0), ,other will lie on her back with her hips slightly raised.

A cover (such as a condom) will be placed over the thin vaginal transducer. %he transducer will be inserted gently into vagina0 and then it will be moved and rotated to ad3ust the view displayed on the monitor. "ome doctors may allow to insert the transducer into vagina herself.

R(151 %here is very little chance of either the mother or the baby having a problem from a biophysical profile ('PP). 'ut she may feel an.ious if the ultrasound reveals a problem with her pregnancy or baby. A nonstress test may falsely show distress in a baby that is actually healthy. S2+&()* 8ach ultrasound assessment is graded either 5 or ! points0 and then added up to yield a number between 5 and =. 8ach variable receives ! points for a normal response or 5 points for an abnormal or absent response. A 'PP of E to = is generally considered reassuring. A 'PP normally is not performed before the second half of a pregnancy0 since fetal breathing movements do not occur in the first half.

B(+4'-1(2#$ 4&+3($! M!#10&!.!)" F!"#$ R!#2"(/("B&!#"'()* .+/!.!)" A%)+&.#$ (6 4+()"1

>nly 1 heart rate increase is seen0 or the heart ! or more heart rate increases of 12 beats per minute or more are rate does not increase by more than 12 beats seen with movement. with movement. 'reathing movement lasts less than #5 seconds0 or no breathing is seen. @ess than # movements of the arms0 legs0 or body %he fetus e.tends slowly and only returns partway to a normal position.

B&!#"'()* .+/!.!)"

1 or more breathing movements last at least #5 seconds.

B+,- .+/!.!)"

# or more movements of the arms0 legs0 or body

M012$! "+)!

Arms and legs are usually fle.ed and the head rests on the chest. %he fetus e.tends but does not return to a 1 or more e.tensions and return to fle.ion are seen0 such as the normal position. opening and closing of a hand. %he arms0 legs0 or spine are e.tended0 or a hand is open. 3$0(, At least one pocket of amniotic fluid of at least !cm is seen in Not enough amniotic fluid is seen in the the uterine cavity. uterine cavity.

A.)(+"(2 /+$0.!

A3"!&2#&!:%he 'PP uses an e.ternal transducer to visuali:e the fetus and the amount of amniotic fluid. A towel or cloth can be used to wipe off e.cess gel and dry the abdomen after the test. In the event that test results indicate fetal compromise0 a health care professional should remain with the mother to provide emotional support and answer ?uestions as needed. C+.4$(2#"(+)1:'ecause the test is noninvasive in nature0 complications from the test itself are une.pected. W'#" A33!2"1 "'! T!1" -easons you may not be able to have the test or why the results may not be helpful include& %he baby is in a position that makes an ultrasound difficult. 'eing unable to lie still throughout the procedure0 which can cause the picture of fetus to be unclear. 'eing overweight0 which may make it difficult to correctly position the e.ternal monitoring device. An infection in either client or fetus. @ow (hypoglycemia) or high (hyperglycemia) blood sugar levels.

%aking medicine0 such as magnesium sulfate. "teroids given to help the babyAs lungs mature. *sing alcohol or illegal drugs0 such as cocaine. In rare cases0 stool (feces) or air in the intestines or rectum interfering with the fetal ultrasound.

R!2+..!),#"(+)1

Additional tests0 such as a contraction stress test0 may be recommended if your results are not normal. For more information0 see the medical test +ontraction "tress %est. If there is a chance that client or fetus may have problems during pregnancy0 she may have a biophysical profile test every week or twice a week during the last 1! weeks of pregnancy. %he chances of having problems may be higher if she have&

+ertain medical conditions0 such as high blood pressure0 kidney disease0 diseases. A history of a stillbirth or preeclampsia. A history of -h incompatibility.

diabetes0 preeclampsia0 or autoimmune

A history of early labor0 premature rupture of membranes (P->,)0 or placenta problems. A baby who seems small for the length of the pregnancy or is not growing (intrauterine growth retardation or restriction). A biophysical profile may be done after an in3ury0 such as a car crash or fall. Cour doctor may recommend additional 'PP tests during the rest of your pregnancy. -esearch is being done on the usefulness of 'PP testing during labor. @ow 'PP test scores may help predict the need for a cesarean section or whether a baby will need specialty care after delivery.

H!#$"' 2#&! "!#. &+$!1: %he 'PP should be performed by a trained ultrasonographer. %he N"% may be performed by a nurse or a radiology technician in the antenatal division of an obstetric department0 in the radiology department0 or in an obstetric office. As with any test0 patient an.iety is heightened with concerns of fetal compromise. %herefore0 the ability of the R!10$"1 A biophysical profile ('PP) test measures the health of fetus during pregnancy. %he results are scores on five measurements in a #5 minute observation period. A score of = to 15 points means that fetus is healthy. A score of E to = points means that it may need to be retested in 1! to !1 hours. A score of 1 or less may mean the baby is having problems. Further testing will be recommended.

2. FETAL ULTRASONOGRAPHY >bstetric *ltrasound is the use of ultrasound scans in pregnancy. "ince its ()"&+,02"(+) in the late 1;25s ultrasonography has become a very useful diagnostic tool in >bstetrics. +urrently used e?uipments are known as &!#$-"(.! 12#))!&10 with which a continous picture of the moving fetus can be depicted on a monitor screen. /ery high fre?uency sound waves of between #.2 to <.5 megahert: (i.e. #.2 to < million cycles per second) are generally used for this purpose.

Fetal ultrasound is a test done during pregnancy that uses reflected sound waves to produce a picture of a fetus0 the organ that nourishes the fetus (placenta)0 and the li?uid that surrounds the fetus (amniotic fluid). %he picture is displayed on a %/ screen and may be in black and white or in color. %he pictures are also called a sonogram0 echogram0 or scan0 and they may be saved as part of your babyAs record. Fetal ultrasound is the safest way to check for problems and get information about fetus0 such as its si:e and position. It does not use G rays or other types of radiation that may harm fetus. It can be done as early as the 2th week of pregnancy. %he se. of the fetus can sometimes be determined by about the 1=th week of pregnancy. T'! .#() 01!1 +3 0$"&#1+)+*&#4'- #&! () "'! 3+$$+7()* #&!#1:

1. D(#*)+1(1 #), 2+)3(&.#"(+) +3 !#&$- 4&!*)#)2-. %he gestational sac can be visuali:ed as early as four and a half weeks of gestation and the yolk sac at about five weeks. %he embryo can be observed and measured by about five and a half weeks. *ltrasound can also very importantly confirm the site of the pregnancy is within the cavity of the uterus.

2. 8#*()#$ %$!!,()* () !#&$- 4&!*)#)2-. %he viability of the fetus can be documented in the presence of /#*()#$ %$!!,()* () !#&$- 4&!*)#)2-. A visible heartbeat could be seen and detectable by pulsed doppler ultrasound by about E weeks and is usually clearly depictable by < weeks. If this is observed0 the probability of a continued pregnancy is better than ;2 percent. ,issed abortions and blighted ovum will usually give typical pictures of a deformed gestational sac and absence of fetal poles or heart beat. Fetal heart rate tends to vary with gestational age in the very early parts of pregnancy. Normal heart rate at E weeks is around ;5 115 beats per minute (bpm) and at ; weeks is 115 1<5 bpm. At 2 = weeks a bradycardia (less than ;5 bpm) is associated with a high risk of miscarriage.

3. D!"!&.()#"(+) +3 *!1"#"(+)#$ #*! #), #11!11.!)" +3 3!"#$ 1(9!. Fetal body measurements reflect the gestational age of the fetus. %his is particularly true in early gestation. In patients with uncertain last menstrual periods0 such measurements must be made as early as possible in pregnancy to arrive at a correct ,#"()* for the patient. In the latter part of pregnancy measuring body parameters will allow assessment of the si:e and growth of the fetus and will greatly assist in the diagnosis and management of intrauterine growth retardation (I*9-). %he following measurements are usually made& a. T'! C&+7)-&0.4 $!)*"' (+-@) %his measurement can be made between < to 1# weeks and gives very accurate estimation of the gestational age. $ating with the +-@ can be within # 1 days of the last menstrual period. An important point to note is that when the due date has been set by an accurately measured +-@0 it should not be changed by a subse?uent scan. For e.ample0 if another scan done E or = weeks later says that one should have a new due date which is further away0 one should not normally change the date but should rather interpret the finding as that the baby is not growing at the e.pected rate. b. T'! B(4#&(!"#$ ,(#.!"!& ('P$) %he diameter between the ! sides of the head. %his is measured after 1# weeks. It increases from about !.1 cm at 1# weeks to about ;.2 cm at term. $ifferent babies of the same weight can have different head si:e0 therefore dating in the later part of pregnancy is generally considered unreliable. $ating using the 'P$ should be done as early as is feasible. c.T'! F!.0& $!)*"' (F@) ,easures the longest bone in the body and reflects the longitudinal growth of the fetus. Its usefulness is similar to the 'P$. It increases from about 1.2 cm at 11 weeks to about <.= cm at term. "imilar to the 'P$0 dating using the F@ should be done as early as is feasible. d) T'! A%,+.()#$ 2(&20.3!&!)2! (A+) %he single most important measurement to make in late pregnancy. It reflects more of fetal si:e and weight rather than age. "erial measurements are useful in monitoring growth of the fetus. A+ measurements should not be used for dating a fetus.

>ther important measurements are %he weight of the fetus at any gestation can also be estimated with great accuracy using polynomial e?uations containing the 'P$0 F@0 and A+. computer softwares and lookup charts are readily available. For e.ample0 a 'P$ of ;.5 cm and an A+ of #5.5 cm will give a weight estimate of !.=2 kg.

4. D(#*)+1(1 +3 3!"#$ .#$3+&.#"(+). ,any structural abnormalities in the fetus can be reliably diagnosed by an ultrasound scan0 and these can usually be made before !5 weeks. +ommon e.amples include hydrocephalus0 anencephaly0 myelomeningocoele0 achondroplasia and other dwarfism0 spina bifida0 e.omphalos0 9astroschisis0 duodenal atresia and fetal hydrops. Fith more recent e?uipment0 conditions such as cleft lips4 palate and congenital cardiac abnormalities are more readily diagnosed and at an earlier gestational age. First trimester ultrasonic AsoftA markers for chromosomal abnormalities such as the absence of fetal nasal bone0 an increased fetal nuchal translucency (the area at the back of the neck) are now in common use to enable detection of $own syndrome fetuses.

*ltrasound can also assist in other diagnostic procedures in prenatal diagnosis such as amniocentesis0 chorionic villus sampling0 cordocentesis (percutaneous umbilical blood sampling) and in fetal therapy.

5. P$#2!)"#$ $+2#$(9#"(+). *ltrasonography has become indispensible in the locali:ation of the site of the placenta and determining its lower edges0 thus making a diagnosis or an e.clusion of placenta previa. >ther placental abnormalities in conditions such as diabetes0 fetal hydrops0 -h isoimmuni:ation and severe intrauterine growth retardation can also be assessed.

6. M0$"(4$! 4&!*)#)2(!1. In this situation0 ultrasonography is invaluable in determining the number of fetuses0 the chorionicity0 fetal presentations0 evidence of growth retardation and fetal anomaly0 the presence of placenta previa0 and any suggestion of twin to twin transfusion.

:. H-,&#.)(+1 #), O$(*+'-,&#.)(+1. 8.cessive or decreased amount of li?uor (amniotic fluid) can be clearly depicted by ultrasound. 'oth of these conditions can have adverse effects on the fetus. In both these situations0 careful ultrasound e.amination should be made to e.clude intraulterine growth retardation and congenital malformation in the fetus such as intestinal atresia0 hydrops fetalis or renal dysplasia.

;. O"'!& #&!#1. *ltrasonography is of great value in other obstetric conditions such as& a) confirmation of intrauterine death. b) confirmation of fetal presentation in uncertain cases. c) evaluating fetal movements0 tone and breathing in the 'iophysical Profile. d) diagnosis of uterine and pelvic abnormalities during pregnancy e.g. fibromyomata and ovarian cyst. Fetal ultrasound is done to learn about the health of the fetus. $ifferent information is gained at different times (trimesters) during your pregnancy.

11"-"&(.!1"!& fetal ultrasound is done to& o $etermine how your pregnancy is progressing. Find out if you are pregnant with more than 1 o o o o o o o o o
fetus. 8stimate the age of the fetus (gestational age). 8stimate the risk of a chromosome defect0 such as $own syndrome. +heck for birth defects that affect the brain or spinal cord. 2),-"&(.!1"!& fetal ultrasound is done to& 8stimate the age of the fetus (gestational age). @ook at the si:e and position of the fetus0 placenta0 and amniotic fluid. $etermine the position of the fetus0 umbilical cord0 and the placenta during a procedure0 such as an amniocentesis or umbilical cord blood sampling. $etect ma3or birth defects0 such as a neural tube defect or heart problems. 3&,-"&(.!1"!& fetal ultrasound is done to& ,ake sure that a fetus is alive and moving. @ook at the si:e and position of the fetus0 placenta0 and amniotic fluid.

%ransvaginal ultrasound is generally done early in a pregnancy to determine fetal age or to detect a suspected ectopic pregnancy. It is occasionally done late in pregnancy to determine the location of the placenta or in a high risk pregnancy to monitor the length of the cervi..

R!10$" A fetal ultrasound scan uses reflected sound waves to produce a picture of the fetus0 placenta0 amniotic fluid. +lient may not receive information about the test right away. Full results are usually available in 1 or ! days. F!"#$ 0$"&#1+0),

N+&.#$:

%he fetus is the si:e e.pected for its age. %he heart rate and breathing activity of the fetus is normal for its age. If the test is done late in the pregnancy0 the fetus is in the head down position. %he placenta is the si:e e.pected for the stage of the pregnancy and does not cover the cervi.. %he uterus contains an ade?uate amount of amniotic fluid. No birth defects can be seen. (,any minor defects and some ma3or defects are not easily seen. Also0 birth defects do not always show up early in pregnancy.)

A%)+&.#$:

%he fetus is growing more slowly than normal0 is small0 or is underdeveloped for its age. %he fetus is abnormally large for its age. If this test is done late in the pregnancy0 the fetus is in the buttocks down (breech) position 'irth defects0 such as absent kidneys or anencephaly0 are present. %he placenta covers the cervi. (placenta previa). %he uterus contains too much or too little amniotic fluid. %he fetus is developing outside of the uterus (ectopic pregnancy). %he scan shows abnormal tissue instead of a normal fetus (molar pregnancy). %he fetal heartbeat is not present. %his can indicate fetal death.

W'#" A33!2"1 "'! T!1" Fetal ultrasound results may be affected by&

'eing very overweight or obese. "tool (feces) or air in the intestines or rectum. An abnormally low amount of amniotic fluid. "ome fetal positions. Not being able to lie still during the procedure. A very active fetus.

husband may be encouraged to be present during the fetal ultrasound test. A photograph or videotape of the ultrasound image of the fetus is sometimes available to the parents. 8$$ date may be changed based on an ultrasound done in early pregnancy if the ultrasound predicts a different date0 based on fetal si:e and development. *ltrasounds do not always show birth defects. In the third trimester0 fetal ultrasound does not accurately determine fetal age or weight. %he effects of prolonged fetal ultrasound e.posure have not been determined6 therefore does not recommend fetal ultrasound for nonmedical reasons0 such as for identifying the se. of the fetus or as personal keepsakes. %hree dimensional (# $) fetal ultrasound is being tested for use in evaluating fetal abnormalities. It is not yet widely available. $oppler ultrasound (or duple. scanning) uses reflected sound waves to estimate the speed and direction of blood as it flows to the placenta and within the fetus.

3.

CONTRACTION STRESS TEST

A 2+)"&#2"(+) 1"&!11 "!1" (+"%) is performed near the end of pregnancy to determine how well the fetus will cope with the contractions of childbirth. %he aim is to induce the contractions and monitor the fetus to check for heart rate abnormalities. A contraction stress test checks to see if the fetus will stay healthy during the reduced o.ygen levels that normally occur during contractions when client is in labor. It involves the release of o.ytocin into the blood stream of the pregnant woman by the stimulation of the nipples. %he target is to achieve around three contractions every ten minutes. %he test includes e.ternal fetal heart monitoring. (nonstress test). %he test is done when you are #1 or more weeks pregnant. An +<-"+2() 2'#$$!)*! "!1" (>+%) is sometimes performed afterwards0 usually if the +"% failed to give clear readings or the uterus did not contract at an appropriate rate. %his involves o.ytocin being given to woman via an intravenous drip.

H(1"+&-: %he test was first introduced in 1;<! and was standardi:ed in 1;<2 when the parameters of contraction number and fre?uency were given. Purposes A contraction stress test is done to check& Fhether the fetus will stay healthy during the reduced o.ygen levels that normally occur during contractions during labor. Fhether the placenta is healthy and can support the fetus. A contraction stress test may be done when results from a nonstress test or a biophysical profile are not in the normal range.

P&!4#&#"(+) +lient may be asked to not eat or drink for 1 to = hours before the test. 8mpty bladder before the test. If client smoke0 stop for ! hours before the test because smoking lowers babyAs activity and heart rate. +lient is asked to sign an informed consent form before a contraction stress test after giving information regarding the need for the test0 its risks0 how it will be done0 or what the results will mean. P&+2!,0&!

A contraction stress test may be done in doctorAs office or hospital by a family medicine doctor or an obstetrician and a trained laboratory technician or nurse. *sually it is not needed to stay overnight. $uring the test0 client will lie on a bed with her back is raised. +lient may tilt a little to her left side so will not have pressure on the blood vessels. %wo belts with sensors will be placed around the belly. >ne belt holds the sensor that records fetus heart rate6 the other sensor measures uterine contractions. 9el may be used on skin with the heart rate sensors. %he sensors are hooked to a recording unit. %he heart rate monitor may be moved if baby changes position. 'abyAs heart rate and clients contractions are recorded for 15 minutes. 'lood pressure and other vital signs are also recorded. %he hormone o.ytocin is given in a low dose and increased until client have three contractions within 15 minutes0 each one lasting longer than 12 seconds. >r she may be asked to massage one of her nipples by hand to start contractions. If she donAt have a second contraction within ! minutes of the first0 she have to massage her nipple again. If contractions do not occur within 12 minutes0 she have to stimulate both nipples. After the test0 she will be watched until her contractions go away or slow down to what they were before the test. A contraction stress test may take ! hours. +lient may need to lie on her left side for the test. %his position may be uncomfortable or painful when she is having labor contractions. %he belts holding the sensors may be uncomfortable. ,ost women say this test is uncomfortable but not painful. A contraction stress test may show decelerations when fetus is not actually having problems. %his is called a false positive result. "ome doctors use o.ytocin instead of nipple stimulation because nipple stimulation can cause long0 uncontrolled contractions

R(151

Fetal heart monitoring may indicate that fetus is having problems when fetus is actually healthy. Fetal heart monitoring cannot detect every type of problem0 such as a birth defect. +ausing labor to start earlier than your e.pected delivery date. +ausing prolonged contractions that may cause problems with your baby. %he contractions usually stop when the o.ytocin is stopped. Cou may be given a medicine to stop the contractions. If in the very rare case that your contractions do not stop0 your doctor may recommend delivery.

C+)"&#(),(2#"(+)1 %his Hstress testH is usually not performed if there are any signs of premature birth or placenta praevia.

R!10$"1 A contraction stress test checks to see if fetus will stay healthy during the reduced o.ygen levels that normally occur during contractions when client is in labor. -esults of the test tell fetus health for 1 week. %he test may need to be done more than once during pregnancy. C+)"&#2"(+) 1"&!11 "!1" N+&.#$: Normal test results are called negative. Fetus heart rate does not get lower (decelerate) and stay low after the contraction (late decelerations). N+"!& %here may be a few times during the test when the heart rate decelerates0 but it doesnAt stay low so it is not a problem. If three contractions occur during a 15 minute period of nipple stimulation or o.ytocin infusion and there are no late decelerations in babyAs heart rate0 baby is e.pected to be able to tolerate the stress of labor. A%)+&.#$: Abnormal test results are called positive. A slower heart rate (late decelerations) that stays low after the contraction may mean that baby will have problems during normal labor. It may also mean that baby will develop problems if delivery is delayed. +ontractions that last longer than ;5 seconds and occur every few minutes are present. %his is called hyperstimulation.

W'#" A33!2"1 "'! T!1" -easons you may not be able to have the test or why the results may not be helpful include&

Past pregnancy problems0 such as a cesarean section with a midline (vertical) incision0 placenta previa0 or placenta abruptio. %he test also is not recommended if client is pregnant with more than one baby0 are likely to have a premature rupture of the amniotic sac (membranes)0 have an incompetent cervi.0 or have been given magnesium sulfate in pregnancy. A uterine surgery in the past. "trong contractions may cause the uterus to rupture. If you smoke or use cocaine. ,ovements of fetus during the test. It may be hard for the sensors to record babyAs heart rate or contractions. 'eing very overweight. 7aving a full bladder. 4. FETAL MO8EMENT COUNT

+ounting the fetal movements is a reliable marker for knowing how well the fetus is. %here is an old saying that IA moving baby is a healthy baby0J and this test helps mother to be more aware of those kicks and flutters by counting them for a period of time each day. %his simple0 low tech procedure0 performed at home0 can and should be used by all women. ,ost women en3oy the counting process0 as it makes them feel closer to their baby. %his test is important to perform during months <0 =0 and ;. health providers can askm to do this test daily during the third trimester. It should be counted at the time of day when baby is usually moving. Not all babies move the same amount or at the same time of day0 so it is important for mother to be aware of babys pattern of movement. P&+2!,0&! %here are two methods of doing fetal heart rate monitoring. +ardif Kcount 15 formula $aily fetal movement count C#&,(3 =2+0)" 16> 3+&.0$# & %he patient counts fetal movements starting at particular time0 say for e.ample ; a.m. %he counting comes to an end as soon as 15 movements are perceived. "he is instructed to report the physician if L 1) less than 15 movements occur during 1! hours on ! successive days or !) no movement is perceived even after 1! hours in a single day.

D#($- 3!"#$ .+/!.!)" 2+0)" (DFMC : %hree counts each of one hour duration (morning0 noon0 and evening) are recommended. %he total counts multiplied by four give daily (1! hour) fetal movement count. If there is diminution of the number of Kkicks to less than 15 in 1! hours (or less than # in each hour)0 it indicates fetal compromise. R!#1+) 3+& $!11 .+/!.!)" Placental insufficiency >ligohydraminos

5.

INTERNAL HEART RATE MONITORING

Internal electronic monitoring is the most precise method for assessing F7- and uterine contractions. A pressure sensing catheter is passed through the vagina0 into the uterine cavity and alongside the fetus0 after the membranes have ruptured and the cervi. has dilated to at least # cm. As contraction puts pressure on the uterine contents0 the pressure e.erted on the catheter is recorded. %he F7- recording is obtained from a fetal scalp electrode. >nce the fetal head is engaged0 the electrode is inserted vaginally and attached to the fetal scalp. A fetal electrocardiograph signal is obtained0 amplified0 and then fed into a cardio tachometer. %he output from the cardio tachometer is recorded on permanent graph paper. It is a invasive procedure0 carries the risk of uterine infection0 and limits a womans movement. RADIOLOGICAL TESTS %his may be used for detection of gross fetal malformations (bony)0 I*F$ or for assessment of fetal maturity where ultrasonography is not available. %hickness and density of the skull bone shadow0 appearance and density of the ossification centers in the upper end of the tibia (#= 15 weeks) and lower end of the femur (#E #< weeks) are taken together to assess the maturity. It is not done these days. G rays may involve risks to an unborn child. P&()2(4$!1 +3 &#,(#"(+) () +%1"!"rics& 'enefits of radiation must outweigh the risks of the procedure ,inimum radiation dose to be used Appropriate fetal shielding should be done First trimester should preferably be avoided 'enefits and safety of ultrasonography must be considered as an alternative 6.

I),(2#"(+)1 #. %. F!"#$ c. d. e. f. g. h. i. M#"!&)#$ 3. ?- R#- '#9#&,1 @ike many medical tests0 . rays have risks as well as benefits. G rays can result in damage of cells or $NA in living matter. %he risk of not having a needed . ray can be much greater than the risk from any e.posure to the radiation. Patient with cardio pulmonary disease may re?uire chest G ray but should be done beyond 1! week $iagnosis of pregnancy ,ultiple pregnancy ,alpresentations 7ydraminos I*$ +ongenital malformations Fetal maturity F!"#$ M#"!&)#$

Fetuses can be unintentionally e.posed to . rays when a woman does not know she is pregnant0 or does not inform the doctor or technician of her pregnancy before an . ray. Fhether planned or unintentional0 e.posure of an unborn child to . rays can cause an.iety to the mother0 which may be more harmful than the . rays themselves. -adiation is not directed towards the fetus during an . ray of the motherAs upper body (chest0 teeth0 neck and limbs). An . ray of the motherAs lower body (abdomen0 lower back0 pelvis0 kidneys) may direct radiation near0 or through0 the fetus. 9enerally these types of . rays only involve small amounts of radiation. %he two types of . rays involving higher amounts of radiation are the abdominal or pelvic +% (computeri:ed tomography) and fluoroscopy. If an . ray cannot be delayed until after pregnancy0 special techni?ues are used to minimi:e the radiation e.posure on the fetus. %he . ray beam can be narrowed to e.pose only a small area0 and in fluoroscopy the e.posure time can be minimi:ed as well. Fetuses are more susceptable than adults to the damaging effects of . rays0 partly because their cells are rapidly dividing and growing into speciali:ed cells and tissues. If . rays cause changes in these cells0 there is a slightly increased chance of birth defects or certain illnesses0 such as leukemia0 later in life. 7owever0 most birth defects and childhood diseases are not attributed to e.posure to any known harmful agent during pregnancy. $amage to fetal cells may result in miscarriage0 birth defects0 or mental impairment0 depending on the amount of radiation and the stage of pregnancy. %he risks are higher during the first three months of pregnancy (first trimester). It is important to note that most of these effects do not usually occur below 155 m9y more radiation than three pelvic +% scans or !5 abdominal . rays. %here is an increased risk of childhood cancer from $NA damage regardless of when in pregnancy the radiation occurred. %he risk is believed to be proportional to the amount of radiation0 i.e. the smaller the amount of radiation0 the smaller the risk of cancer. ,ost studies show no increase in childhood cancer from small amounts of radiation. 7owever0 one study identifies the chance of a childhood cancer from abdominal . rays (in the 15 m9y range) at about one in 10555 births. In comparison0 the chance of a childhood cancer in the general population is about two to three in 10555 births.

II.

BIOCHEMICAL TESTS

Pregnancy induces ma3or physiological0 hormonal and biochemical changes to achieve an optimal outcome for the baby and its mother. Fhen the pregnancy deviates from its normal course0 there are many biochemical markers which can be used to assess these abnormalities. As biochemistry is only one part of obstetric care0 results should be interpreted in con3unction with clinical and medical imaging data. 'iochemical markers are used to assess maternal0 placental and fetal health. %hey help to diagnose and monitor maternal conditions such as gestational diabetes and pre eclampsia0 trophoblastic disease and fetal chromosomal abnormalities such as $ownAs syndrome. %hese biochemical and hormonal tests constitute only one aspect of obstetric care. %hey should be used together with clinical findings and imaging0 particularly ultrasonography.

B(+2'!.(2#$ "!1"1 3+& 2+..+) .#"!&)#$@ 4$#2!)"#$ #), 3!"#$ 2+),("(+)1 C+),("(+) ,aternal 9estational diabetes T!1" 9lucose screening tests at !1 != weeks& 25 g challenge test +& ! hour <2 g oral glucose tolerance test 1. *rinary protein (by dipstick testing or formal ?uantitation) !. "erum uric acid #. -enal function tests 1. Full blood count (for 7b concentration and platelet count) 1. 7+9 !. Free N 7+9 #. *rinary 7+9 when indicated ,aternal serum alpha fetoprotein0 7+90 pregnancy associated plasma protein A0 and transnuchal ultrasound between 11 and 1# weeks gestation %riple test ,aternal serum alpha fetoprotein0 7+90 pregnancy associated plasma protein A0 and serum uncon3ugated oestriol in various

Pre eclampsiaM

Placental

Fetal

%rophoblastic diseaseM (hydatidiform mole or choriocarcinoma) $ownAs syndromeM

combinations between 12 and 1= weeks gestation Neural tube defects ,aternal serum alpha fetoprotein +& Amniotic fluid alpha fetoprotein (less common)

@ung maturity

@ecithin4"phingomyelin (@4") ratio

1.

BIOCHEMICAL ASSESSMENT OF MATERNAL HEALTH

+ommon problems in pregnancy include gestational diabetes and pre eclampsia. $IA'8%8" %he prevalence of gestational diabetes mellitus ranges from 1 to 11O depending on the populations studied. In Australia0 the prevalence ranges from 2.2 to =.=O. "creening for gestational diabetes mellitus in Australia is strongly advocated at !E != weeks of gestation. %his enables early intervention which results in significant improvements in both fetal and maternal outcomes. >ccasionally0 the serum glucose is une.pectedly found to be in the diabetic range in the first trimester. 'y definition0 this is gestational diabetes mellitus0 but does not distinguish between diabetes that may have preceded or occurred at the same time as pregnancy. %he diagnosis can be confirmed by further tests of fasting glucose concentration or a <2 g oral glucose tolerance test. %hese patients should be reassessed in the postpartum period for evidence of diabetes. %he womanAs glycated haemoglobin should be maintained in the normal range or as near normal as possible to ensure optimal fetal outcome. P-8 8+@A,P"IA Pre eclampsia occurs typically in the third trimester and affects 1 =O of pregnancies. It constitutes a triad of pregnancy associated hypertension (that is0 there is no pre e.isting hypertension)0 marked proteinuria (greater than #55 mg daily) and pathological oedema. It is thus critical that urinary dipstick testing for protein0 which can be fully ?uantitated if re?uired0 is performed at each antenatal visit together with blood pressure measurement and careful e.amination for oedema. >ther findings include rises in serum uric acid (which can antedate the onset of hypertension)0 urea and creatinine. @ow haemoglobin and platelet concentrations are informative if the patient is suspected to have the severe form of pre eclampsia haemolysis elevated liver en:ymes low platelets (78@@P). In the absence of pre e.isting pathology0 these biochemical parameters should return to normal after delivery.

2.

BIOCHEMICAL ASSESSMENT OF PLACENTAL HEALTH

*ltrasonography has added another dimension to first trimester obstetric care to such an e.tent that many traditional biochemical tests have been rendered redundant. ,aternal serum human placental lactogen and serum or urinary oestriol concentrations which were previously used e.tensively in the assessment of placental function0 are rarely used nowadays. 7*,AN +7>-I>NI+ 9>NA$>%->P7IN (7+9) H0.#) 2'+&(+)(2 *+)#,+"&+4() ('CG) is a glycoprotein hormone produced in pregnancy that is made by the the developing embryo soon after conception and later by the syncytiotrophoblast (part of the placenta). Its role is to prevent the disintegration of the corpus luteum of the ovary and thereby maintain progesterone production that is critical for a pregnancy in humans. h+9 may have additional functions6 for instance0 it is thought that h+9 affects the immune tolerance of the pregnancy. 8arly pregnancy testing0 in general0 is based on the detection or measurement of h+9. In the second trimester an elevated serum 7+9 concentration has been associated with a two to threefold increased risk of fetal growth retardation. In the second trimester an elevated serum 7+9 concentration has been associated with a two to threefold increased risk of fetal growth retardation. F0)2"(+) 7uman chorionic gonadotropin interacts with the @7+9 receptor and promotes the maintenance of the corpus luteum during the beginning of pregnancy0 causing it to secrete the hormone progesterone. Progesterone enriches the uterus with a thick lining of blood

vessels and capillaries so that it can sustain the growing fetus. $ue to its highly negative charge0 h+9 may repel the immune cells of the mother0 protecting the fetus during the first trimester. It has also been hypothesi:ed that h+9 may be a placental link for the development of local maternal immunotolerance. For e.ample0 h+9 treated endometrial cells induce an increase in % cell apoptosis (dissolution of % cells). %hese results suggest that h+9 may be a link in the development of peritrophoblastic immune tolerance0 and may facilitate the trophoblast invasion0 which is known to e.pedite fetal development in the endometrium. It has also been suggested that h+9 levels are linked to the severity of morning sickness in pregnant women. 'ecause of its similarity to @70 h+9 can also be used clinically to induce ovulation in the ovaries as well as testosterone production in the testes. As the most abundant biological source is women who are presently pregnant0 some organi:ations collect urine from pregnant women to e.tract h+9 for use in fertility treatment. 7uman chorionic gonadotropin also plays a role in cellular differentiation4proliferation and may activate apoptosis. T!1"()* @evels of h+9 may be measured in the blood or urine. ,ost commonly0 this is done as a pregnancy test0 intended to indicate the presence or absence of an implanted embryo. %esting for h+9 may also be done when diagnosing or monitoring germ cell and trophoblastic tumors. ,ost tests employ a monoclonal antibody (,Ab)0 which is specific to the -subunit of h+9 (Nh+9). %his procedure is employed to ensure that tests do not make false positives by confusing h+9 with @7 and F"7. (%he latter two are always present at varying levels in the body0 whereas the presence of h+9 almost always indicates pregnancy.)

%he urine test may be a chromatographic immunoassay or any of several other test formats0 home 0 physicianAs office 0 or laboratory based. Published detection thresholds range from !5 to 155 mI*4ml (milli International *nits per milli liter)0 depending on the brand of test. 8arly in pregnancy0 more accurate results may be obtained by using the first urine of the morning when h+9 levels are highest. Fhen the urine is dilute (specific gravity less than 1.512)0 the h+9 concentration may not be representative of the blood concentration0 and the test may be falsely negative. %he serum test0 using ! 1 m@ of venous blood0 is typically a chemiluminescent or fluorimetric immunoassay that can detect Nh+9 levels as low as 2 mI*4ml and allows ?uantitation of the Nh+9 concentration. %he ability to ?uantitate the Nh+9 level is useful in the monitoring germ cell and trophoblastic tumors0 followup care after miscarriage0 and in diagnosis of and follow up care after treatment of ectopic pregnancy. %he lack of a visible fetus on vaginal ultrasound after the Nh+9 levels have reached 1255 I*4ml is strongly indicative of an ectopic pregnancy.

9estational trophoblastic disease like 7ydatidiform moles (Hmolar pregnancyH) or +hroiocarcinoma may produce high levels of Nh+9 (due to the presence of syncytialtrophoblasts part of the villi that make up the placenta) despite the absence of an embryo. %his0 as well as several other conditions0 can lead to elevated h+9 readings in the absence of pregnancy. h+9 levels are also a component of the triple test0 a screening test for certain fetal chromosomal abnormalities4birth defects. 'CG L!/!$1 %he following is a list of serum h+9 levels. Note that these are merely typical values a given womanAs values may not fall within these ranges. (@,P P since last menstrual period).

# weeks @,P& 2 25 mI*4ml 1 weeks @,P& 2 1!E mI*4ml 2 weeks @,P& 1= <0#15 mI*4ml E weeks @,P& 105=5 2E0255 mI*4ml < = weeks @,P& <0 E25 !!;0555 mI*4ml ; 1! weeks @,P& !20<55 !==0555 mI*4ml 1# 1E weeks @,P& 1#0#55 !210555 mI*4ml 1< !1 weeks @,P& 105E5 1E20155 mI*4ml !2 15 weeks @,P& #0E15 11<0555 mI*4ml Non pregnant females& Q2.5 mI*4ml Postmenopausal females& Q;.2 mI*4ml

T0.+& .#&5!&

%he subunit of human chorionic gonadotropin is secreted also by some cancers including choriocarcinoma0 germ cell tumors0 hydatidiform mole formation0 teratoma with elements of choriocarcinoma (this is rare)0 and islet cell tumor. For this reason a positive result in males can be a test for cancer0 %he normal range for men is between 5 2 I*4ml0 although cancer should not automatically be suspected if the level is Q#5. U1! #1 .!,(2#"(+) 7uman chorionic gonadotropin is e.tensively used as a parenteral fertility medication in lieu of luteini:ing hormone. In the presence of one or more mature ovarian follicles0 ovulation can be triggered by the administration of h+9. As ovulation will happen about #E 1= hours after the in3ection of h+90 procedures can be scheduled to take advantage of this time se?uence. %hus0 patients that undergo I/F0 in general0 receive h+9 to trigger the ovulation process0 but have their eggs retrieved at about #E hours after in3ection0 a few hours before the eggs actually would be released from the ovary. As h+9 supports the corpus luteum0 administration of h+9 is used in certain circumstances to enhance the production of progesterone. In the male0 h+9 in3ections are used to stimulate the leydig cells to synthesi:e testosterone. %he intratesticular testosterone is necessary for spermatogenesis from the sertoli cells. %ypical uses for h+9 in men include hypogonadism and fertility treatment. $uring first few months of pregnancy0 the transmission of 7I/ 1 from woman to fetus is e.tremely rare. It has been suggested that this is due to the high concentration of h+90 and that the beta subunit of this protein is active against 7I/ 1. U1! () 7!(*'" $+11 A controversial usage of h+9 is as an ad3unct to the 'ritish endocrinologist $r. A.%.F. "imeons ultra low calorie weight loss diet. "imeons0 while studying pregnant women in India on a calorie deficient diet0 and Ifat boysJ with pituitary problems treated with low dose h+90 discovered that both lost fat rather than lean (muscle) tissue. 7e reasoned that h+9 must be programming the hypothalamus to do this in the former cases in order to protect the developing fRtus0 and proceeded to use low dose daily h+9 in3ections (1!2mg) in combination with a customi:ed ultra low calorie (255 kcal4day0 high protein0 low carbohydrate4fat) diet to help obese adults lose dramatic amounts of adipose tissue without loss of lean0 at a "alvator ,undi International 7ospital in -ome0 Italy0 clinic mainly for celebrities.

3.

BIOCHEMICAL ASSESSMENT OF FETAL HEALTH

%he ma3or aim of fetal assessment is to ensure satisfactory growth in utero. %here are many factors which can cause fetal growth retardation. %hese range from poor maternal nutritional state to placental insufficiency and fetal abnormality. "imilar to placental function0 medical imaging is increasingly used to detect fetal abnormalities0 thus reducing the utility of biochemical markers. A@P7A F8%>P->%8IN Alpha fetoprotein is a fetal protein arising from the yolk sac and fetal liver. It can be detected in increasing concentrations in maternal serum until #! weeks of normal gestation. @ab+orp0 a large *" clinical laboratory testing company0 began offering AFP screening tests in the early 1;=5s. AFP test results often are reported as either ng4ml or ,o, (multiple of the median0 where the median is calculated for an appropriate reference population). %he normal range of AFP for adults and children is variously reported as under 250 under 150 and under 2 ng4m@. At birth0 normal infants have AFP levels 1 or more orders of magnitude above this normal range0 decreasing to within it over the first 1L! years of life. $uring this time0 the normal range of AFP levels spans appro.imately ! orders of magnitude. +orrect evaluation of abnormal AFP levels in infants must take into account these normal patterns. %here are two categories of AFP tests& tests performed on serum (blood plasma)0 and tests performed on amniotic fluid. %ests performed on serum are further categori:ed by the reason for performing the test& maternal serum0 adult tumor marker0 and pediatric tumor marker. T!1"1 4!&3+&.!, +) 1!&0.

%he standard is a ?uantitative test0 reporting a measured concentration of AFP in the sample0 but there is also a less e.pensive ?ualitative test0 reporting only that the concentration is normal or high. %he ?ualitative test is appropriate only in some circumstances. %he resulting test report should specify the assay method and e?uipment used0 and the report of a ?uantitative test should also provide a reference range for the test result. ,any laboratories report reference ranges that are based on all other samples tested in that laboratory0 necessarily including samples with abnormal AFP concentrations due to disease. "uperior reference ranges are produced by research on healthy sub3ects. M#"!&)#$ 1!&0. ,aternal serum AFP (MSAFP) varies by orders of magnitude during the course of a normal pregnancy. ,"AFP increases rapidly until about #! weeks gestation0 then decreases gradually. After the pregnancy ends it decreases rapidly0 with a half life of about 2 days. %ypically0 ,"AFP is measured in the beginning of the second trimester (11 1E weeks). It may be measured alone or as part of a package of routine prenatal screening tests0 such as a triple test or ?uad test. 'ecause ,"AFP test results must be interpreted according to the gestational age0 they often are reported in terms of multiple of the median (,o,). 'ecause the median is calculated from tests of other womenAs pregnancies at the same gestational age0 in effect ,o, is independent of gestational age. A typical normal range is 5.2 to !.5 or !.2 ,o,. ,"AFP above normal is seen in multiple gestation0 when there is placental abruption0 as well as in a number of fetal abnormalities0 such as neural tube defects including spina bifida and anencephaly0 and abdominal wall defects. >ther possibilities are errors in the date of the gestation or fetal demise. -arely0 high ,"AFP is due to endodermal sinus tumor (8"%) or another germ cell tumor containing 8"%. %hese tumors can occur in the pregnant woman (often as an ovarian tumor) or in the fetus. ,"AFP below normal is associated with a smaller number of conditions0 including $own syndrome and %risomy 1=. $iabetic patients also have lower levels. Patients with abnormal ,"AFP need to undergo detailed obstetric ultrasonography. %he information is then used to decide whether to proceed with amniocentesis. 9enetic counseling usually is offered when the screening test result is positive. Neural tube defects In neural tube defects such as spina bifida and anencephaly0 the concentration of alpha fetoprotein in the maternal serum is unusually high in the first trimester because cerebrospinal fluid leaks into the amniotic fluid. >ther causes of elevated alpha fetoprotein0 such as incorrect gestational date and multiple pregnancy0 need to be e.cluded. As a marker of neural tube defects maternal serum alpha fetoprotein0 ideally0 should be measured between 12 and 1= weeks of gestation. Any suspicion of a neural tube defect can be further assessed with ultrasound0 usually at 1= !5 weeks. %his scan also assesses for other fetal morphological abnormalities and placental placement. $ownAs syndrome $ownAs syndrome is one of the common causes of fetal growth retardation. It is the result of either partial or total trisomy of chromosome !1 and is a ma3or obstetric concern0 particularly in older women. Important biochemical markers include alpha fetoprotein0 7+90 uncon3ugated oestriol0 pregnancy associated plasma protein A0 serum inhibin A and free N 7+9. %hese markers are used in various combinations and together with ultrasound to increase the detection rate of $ownAs syndrome. It cannot be overemphasised that the gestational age must be correct in order for screening parameters to be accurate. 'etween 11 and 1# weeks (that is late first trimester)0 serum pregnancy associated plasma protein A0 free N 7+9 and ultrasound assessment of nuchal thickness (the physiological space between the back of the neck and the overlying skin of the fetus) are most commonly used in the assessment of $ownAs syndrome. $ue to the changing concentrations of these markers in the normal pregnant population0 the results are mathematically corrected for easy comparison. %he nuchal thickness is increased in $ownAs syndrome and appro.imately <5O of cases will be detected by ultrasound in e.perienced centres. In combination with biochemical markers0 the detection rate increases to =2 ;5O. Abnormal results can be followed up with direct karyotyping using chorionic villous sampling0 but this carries a 5.2 1.5O risk of pregnancy loss in the first trimester. In the second trimester0 screening for $ownAs syndrome traditionally employs the triple test of maternal serum 7+90 serum uncon3ugated oestriol and alpha fetoprotein at 12 1= weeks of gestation. "ome laboratories also measure serum pregnancy associated plasma protein A. %he combination of these markers and maternal age delivers a E5 E2O detection rate0 but this includes the 2O of women who have a false positive result. %ransnuchal thickness in the mid to late second trimester does not correlate well with $ownAs syndrome and does not add to the value of biochemical markers.

%he results of $ownAs syndrome screening in the first and second trimester are e.pressed as the proportion of affected pregnancies0 for e.ample 1 in 1== chance of having $ownAs syndrome. %his is accomplished using a risk assessment program that incorporates nuchal thickness (only in the first trimester)0 biochemistry results and maternal age. 'I@I-*'IN IN A,NI>%I+ F@*I$ Another biochemical method of assessing fetal health is the analysis of amniotic fluid. %he measurement of bilirubin concentration in amniotic fluid is critical for assessing fetal intravascular haemolysis in the presence of -hesus incompatability. >%78-" -ecently0 there has been a resurgence of interest using maternal growth hormone and insulin like growth factor levels during the first and second trimester of pregnancy as predictors of fetal outcome0 but these are yet to be of routine clinical use. A""8"",8N% >F F8%A@ P*@,>NA-C ,A%*-I%C +onfirmation reduces the incidence of respiratory distress syndrome (-$") in the new born. -$" is high in premature infants born before #< yrs. It is caused by deficiency of pulmonary surfactant synthesi:ed by type II alveolar cells. "urfactant is packed in lamellar bodies which is discharged in lung alveoli which is carried in the pulmonary fluid which carried into the amniotic fluid. 'y @ecithin4 "phingomylin (@4") ratio Amniotic fluid @4" ratio at #1 #! weeks is 10 at #2 weeks is ! and @4" ratio S ! indicates lung maturity. >ther tests which determine lung maturity are& k. l. presence of Phosphatidyl glycerol saturated Phosphatidyl choline S 255ng4ml

m. Amniotic fluid optical density at E25m greater than 5.12 n. Amniotic fluid color during 1st and !nd trimester is yellow and clear. At term is turbid due to verni.

III.

CYTOGENIC TESTS

%hey are helpful in prenatal diagnosis of genetic disorders. $ifferent tests comes under this category are& 1. !. #. C'+&(+)(2 /($$01 1#.4$()* C+&,+2!)"!1(1 A.)(+2!)"!1(1

4.

C'+&(+)(2 /($$01 1#.4$()*

C'+&(+)(2 /($$01 1#.4$()* (C8S is a form of prenatal diagnosis to determine chromosomal or genetic disorders in the fetus. It entails getting a sample of the chorionic villus (placental tissue) and testing it. %he advantage of +/" is that it can be carried out 15 1# weeks after the last period0 earlier than amniocentesis (which is carried out at 1E !5 weeks). +horionic villus sampling (+/") is the removal of a small piece of placenta tissue (chorionic villi) from the uterus during early pregnancy to screen the baby for genetic defects. I),(2#"(+)1 Possible reasons for having a +/" can include&

,otherAs age of #2 years or greater Abnormal first trimester screen results Increased nuchal translucency or other abnormal ultrasound findings Family history of a chromosomal abnormality or other genetic disorder

Parents are known carriers for a genetic disorder %he test is a way of detecting genetic disorders. %he sample is used to study the $NA0 chromosomes0 and en:ymes of the fetus. It can be done sooner than amniocentesis0 about 15 to 1! weeks after your last menstrual period. %est results take about 1 to ! weeks0 whereas amniocentesis results may take longer.

P&!4#&#"(+) 7ealth care provider will e.plain the procedure0 its risks0 and alternative procedures such as amniocentesis. 9enetic counseling is recommended prior to the procedure. %his will allow client to make an unhurried0 informed decision regarding options for prenatal diagnosis. +lient will be asked to sign a consent form before this procedure0 and may be asked to wear a hospital gown. %he morning of the procedure client may be asked to drink fluids and refrain from urinating to fill bladder0 which allows ade?uate visuali:ation so the sample may be taken. An obstetrician can perform this procedure in about 2 minutes0 after the preparation.

P&+2!,0&! +/" can be done through the cervi. (transcervical) or through the abdomen (transabdominal). %he techni?ues are e?ually safe when done by a provider with e.perience0 although miscarriage rates are slightly higher when done through the cervi.. %he health care provider will use ultrasound to pick the safest approach and as a guide during sampling. An abdominal ultrasound is performed to determine the position of the uterus0 the si:e of the gestational sac0 and the position of the placenta within the uterus. Cour vulva0 vagina0 cervi.0 and abdomen are cleaned with an antiseptic such as 'etadine. %he transcervical procedure is performed by inserting a thin plastic tube through the vagina and cervi. to reach the placenta. %he provider uses ultrasound images to help guide the tube into the appropriate area and then removes a small sample of chorionic villus tissue. %he transabdominal procedure is performed by inserting a needle through the abdomen and uterus and into the placenta. *ltrasound is used to help guide the needle0 and a small amount of tissue is drawn into the syringe. %he sample is placed in a dish and evaluated in a laboratory. %he ultrasound doesnAt hurt. A clear0 water based conducting gel is applied to the skin to help with the transmission of the sound waves. A handheld probe called a transducer is then moved over the area. In addition0 your health care provider may apply pressure on your abdomen to find the position of your uterus. %he antiseptic cleansing solution will feel cold at first asnd may irritate your skin if not washed off after the procedure. "ome people are allergic to 'etadine. Notify your health care provider if you are allergic to 'etadine or if you have any other allergies. "ome women say the vaginal approach feels like a Pap smear with some discomfort and a feeling of pressure. %here may be a small amount of vaginal bleeding following the procedure.

R!10$"1 N+&.#$ &!10$" %here are no signs of any genetic defects. 7owever the test could miss some genetic defects. Note& Normal value ranges may vary slightly among different laboratories. %alk to your doctor about the meaning of your specific test results. A%)+&.#$ R!10$"1 An abnormal result may be a sign of more than !55 disorders0 including&

$own syndrome 7emoglobinopathies %ay "achs disease

L(.("#"(+)1 A small percentage (1 !O) of pregnancies will have confined placental mosaicism0 where some but not all of the placental cells tested in the +/" will be abnormal0 even though the pregnancy is unaffected. +ells from the mother can be mi.ed with the placental cells obtained from the +/" procedure. >ccasionally if these maternal cells are not completely separated from the placental sample0 this can lead to discrepancies with the results. %his phenomenon is called ,aternal +ell +ontamination (,++). +/" can not detect

all birth defects. ItAs used for testing chromosomal abnormalities or other specific genetic disorders only if there is family history or other reason to test. R(151 Possible complications include&

'leeding Infection ,iscarriage -h incompatibility in the mother -upture of membranes Amniotic fluid leak which can further leads to >ligohydraminos if not treated and the amniotic fluid continues to leak it can result in the baby developing 7ypoplastic lungs (underdeveloped lungs). +/" may also cause limb problems in the fetus. %his risk appears to be very low (1 in #0555) when +/" is performed after 15 weeks gestational age.

"igns of complications include&

8.cessive bleeding 8.cessive vaginal discharge Fever

Any signs of complications should be reported to health care provider. C+)1(,!&#"(+)1 If your blood is -h negative0 client may -ho9A, to prevent -h incompatibility. A follow up ultrasound should be done ! to 1 days after the procedure to make sure the pregnancy is proceeding normally.

5.

CORDOCENTESIS: FETAL BLOOD SAMPLING

+ordocentesis or P*'" (Percutaneous umbilical blood sample) is a diagnostic test that e.amines blood from the fetus to detect fetal abnormalities. T(.!: +ordocentesis is usually done when diagnostic information can not be obtained through amniocentesis6 +/"0 ultrasound or the results of these tests were inconclusive. +ordocentesis is performed at 1= weeks or after. O%A!2"(/! +ordocentesis detects chromosome abnormalities (i.e. $own syndrome) and blood disorders (i.e. fetal hemolytic disease.). +ordocentesis may be performed to help diagnose any of the following concerns&

,alformations of the fetus Fetal infection (i.e. to.oplasmosis or rubella) Fetal platelet count in the mother Fetal anemia Isoimmunisation

%his test is different from amniocentesis in that it does not allow testing for neural tube defects. P&+2!,0&!

An advanced imaging ultrasound determines the location where the umbilical cord inserts into the placenta. %he ultrasound guides a thin needle (!2 gauge spinal needle 1# cm in length) through the abdomen and uterine walls to the umbilical cord. %he needle is inserted into the umbilical vein apro. 1 ! cm from the placental insertion to retrieve a small sample of fetal blood (5.2 to ! ml). %he sample is sent to the laboratory for analysis0 and results are usually available within <! hours. %he procedure is similar to amniocentesis e.cept the ob3ective is to retrieve blood from the fetus versus amniotic fluid. It is performed under local anesthesia. Anti $ Immunoglobulin 155 g i4m given to -h negative. R!10$" +ordocentesis is a diagnostic test that detects chromosome abnormalities and certain blood disorders with high levels of accuracy. Although the probabilities of identification are high0 this test does not measure the severity of these disorders. %his test also does not help identify neural tube defects. S(,! !33!2"1 Although cordocentesis is considered to be a safe procedure0 it is recogni:ed as an invasive diagnostic test that does pose potential risks. ,iscarriage is the primary risk related to cordocentesis occurring between 1 to ! times out of every 155 procedures. >ther potential side effects include&

'lood loss from the puncture site 7aematoma formation Infection $rop in fetal heart rate Premature rupture of membranes

+ontact your healthcare provider if these symptoms remain or get worse. Cou should also contact your healthcare provider if you e.perience&

Fever +hills @eaking of amniotic fluid

R!#1+)1 "+ "!1" %he reasons to test or not test vary from person to person0 couple to couple and physician to physician. Performing the tests and confirming the diagnosis provides you with certain opportunities&

Pursue potential medical interventions that may e.ist 'egin planning for a child with special needs "tart addressing anticipated lifestyle changes Identify support groups and resources ,ake a decision about carrying the child to term

E.AMNIOCENTESIS It is the deliberate puncture of the amniotic fluid sac per abdomen. P0&4+1!1 $iagnoses of chromosomal and genetic disorders 8arly months 1. "e. linked disorders !. #. Inborn errors of metabolism Neural tube defect

@ater months

1. !. #. 1. P&!2!,0&!

Fetal maturity $egree of fetal hemolysis in -h n ve mother ,econium staining Amniography and fetography

1. 2. 3. 4.

8mpty the bladder @ie on dorsal position Proposed puncture site is infiltrated with !ml of 1O lignocane "ites are 6early pregnancy is 14#rd of the way up the uterus from symphysis pubisand later is transisthemic superapubis approach after lifting the presenting part or through the flanks in between the fetal limbs or below the umbilicus behind the neck of the fetus A 1= to !5 gau:e spinal needle about 1 in length is pierced under *"9 with the stilette in. "tiletto is withdrawn and few drops are discarded #5ml of fluid is collected in a test tube

5. 6. :. I8.

MATERNAL ASSAY

P0&4+1!1 1. Prevention early detection and treatment of medical disorders as anaemia and diabetes. !. #. 1. $etection of malpresentations0 malpositions and disproportion that may influence the decision of labour. Instruct the pregnant woman about hygience0 diet and warning symptoms. @aboratory studies of parameters may affect the foetus as blood group0 -h typing0 to.oplasmosis and syphilis.

P&+2!,0&!1 #" "'! /(1(" %he first visit should not be deferred beyond the second missed period. It may be earlier if the patient desires to terminate the pregnancy. F&!B0!)2- +3 #)"!)#"#$ /(1("1. every month during the first E months. every ! weeks during the <th and =th months. every week during the last month. ,ore fre?uent visits are indicated in high risk pregnancy. M!"'+, #. I)14!2"(+) C %he si:e of the uterus %he shape of the uterus Fetal movement +ontour of the abdominal wall "kin changes %. P#$4#"(+)1 7ands should be clean and warm before doing palpations L as 2+$, '#),1 do not have the necessary acute sense of touch they tend to induce contraction of the uterine muscles and the mother resents the discomfort. Arms and hands should be rela.ed and the pads0 not the tips0 of the fingers used with delicate precision. %he hands are moved smoothly over the abdomen in a stroking motion in order to avoid causing contractions. 8stimating the period of gestation Fundal palpation @ateral palpation Pelvic palpation

F0),#$ 4#$4#"(+) First maneuver Face the patient and warm your hands. Place them on her abdomen to determine fetal position in the uterine fundus. +url your fingers around the fundus. Fith the fetus in verte. position0 the buttocks feel irregularly shaped and firm. Fith the fetus in breech position0 the head feels hard0 round0 and movable. Second maneuver 4 $#"!&#$ 4#$4#"(+) ,ove your hands down the sides of the abdomen0 and apply gentle pressure. If the fetus lies in verte. position0 youAll feel a smooth0 hard surface on one side T the fetal back. >pposite0 youAll feel lumps and knobs T the knees0 hands0 feet0 and elbows. If the fetus lies in breech position0 you may not feel the back at all. Third maneuver "pread apart the thumb and fingers of one hand. Place them 3ust above the patientAs symphysis pubis. 'ring your fingers together. If the fetus lies in verte. position and hasnAt descended0 youAll feel the head. If the fetus lies in verte. position and has descended0 youAll feel a less distinct mass. Fourth maneuver *se this maneuver in late pregnancy when the fetus is in cephalic presentation. %he purpose of the fourth maneuver is to determine fle.ion or e.tension of the fetal head and neck. Place your hands on both sides of the lower abdomen. Apply gentle pressure with your fingers as you slide your hands downward0 toward the symphysis pubis. If the head and neck are fle.ed0 your hands will meet obstruction T the cephalic prominence T on the side opposite the fetal back. If the head and neck are e.tended0 the cephalic prominence will be palpated on the same side as the fetal back. Fle.ion of the fetal head and neck facilitates vaginal delivery. P#$4#"(+) 7($$ '!$4 "+ (,!)"(3 Fundal height @ie Presentation Attitude Position 8ngagement L it means the descent of the biparietal diameter through the pelvic brim. 2. A0120$"#"(+) %he fetoscope and the $oppler stethoscope are basic instruments for auscultating fetal heart tones and assessing fetal heart rate. Fetoscope %his instrument can detect fetal heartbeats as early as the !5th gestational week. As an assessment tool during labor0 the fetoscope is helpful for hearing fetal heart tones when contractions are mild and infre?uent.