Preeclampsia

Fetal Assessment
Aria Wibawa
Dept. Obstetric and Gynecologic dr. Cipto Mangunkusumo Hospital
Workshop Gestosis, Four Season Hotel Jakarta
Mei 2012

Fetal Assessment
A method to evaluate fetal well being
! Fetal well being: Fetal on good condition, comfort,
safe, free from ill, stress, and life threat
!

Fetal well being is related with:

! Tissue perfusion (oxygenation)
! Tissue metabolic process (glucose/ calories)
! Exchange material process continuity
! Acid-base status

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Definition
! Fetal distress: Disturbance in fetal physiology that may cause death or

permanent damage in a relatively short period of time. (Kirschbaum TH.

Diagnosis of fetal distress. Am J Obstet Gynecol. 1969; 34: 721-8).

! Fetal stress: a condition that precedes fetal distress. (Boehm FH. Fetal distress.
In: Eden RD, Boehm FH. Assessment & care of the fetus. Prentice-Hall Int.; 1990)

Gawat janin: kondisi janin mengalami gangguan atau

ancaman terhadap kesejahteraan janin yang ditandai dengan
asfiksia sehingga menyebabkan gangguan atau kerusakan
fungsi sistem organ baik reversibel atau ireversibel hingga
kematian

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Oxygenation
disturbance

Metabolic
disturbance
Stressor

Hypoxia

Hypoglycemia

Fetal responses : adaptation/compensations

Compensated
No-mild metabolic acidosis

No organ/ tissue
damage

Normal

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Uncompensated
intermediate- severe metabolic acidosis

Reversible
organ/tissue damage

Normal

Irreversible
organ/ tissue damage

Sequel: abnormalities, IUGR, RDS,

NEC, renal failure, epilepsy, cerebral
palsy, autism, focus disability, etc.
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Death

Fetal responses to hypoxia

Increase baseline heart rate

Increase hemoglobin concentration
Improved cardiac contractility/ efficiency
Increase oxygen extraction

! Increase oxygen supply

! Control oxygen distribution
! Reduce oxygen consumption
Reduce/disappearance of heart rate
reactivity before fetal breathing movement,
then fetal movement
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Cardiomegaly
High arterial velocity

Preservation of vital organs

oxygenation: brain, heart,
adrenal, and placenta
Reduction in other organ:
mesenteric, renal, distal aortic
outflow track
Asymmetric IUGR
Oligohydramnion
Brain sparring effect
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Fetal assessment
! The conclusion from fetal assessment:
! Normal condition; good fetal well being
! Placental insufficiency
! Fetal hypo-perfusion
! Fetal stress; compensated fetal hypoxia/hypo-perfusion
! Fetal distress; uncompensated fetal hypoxia/ hypo-perfusion
! etc.

! The goal of fetal assessment is to prevent perinatal death

(ACOG 1999)
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Preeclampsia pathogenesis

Maternal site
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Fetal site
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Preeclampsia pathogenesis
Maternal site
A. Spiralis

Non pregnant

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Normal Pregnancy

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Preeclampsia

High resistant vascular

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Preeclampsia pathogenesis
Fetal site
Wide spectrums of villous lesions
! Hypovascular villi
! Cytotrophoblastic proliferation
! Endarteritis obliterans
! Paucity of vasculosyncytial
! Thickening of basement membrane
! Increased of syncytial knots
! Increased villous stromal fibrosis
! Increased fibrinoid necrosis
! Intervillous hemorrhages
! Increased of extra-villous
cytotrophoblastic
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Inter villous thrombus

Infark
Fibrin deposit

Placental insufficiency
High resistant vascular
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Fetal assessment based on

preeclampsia pathogenesis
Pathogenesis

Assessment

High resistant utero-placenta circulation

Maternal uterine artery

High resistant intra-placenta circulation

Intra placenta vascularization index ?

Morphology of placenta ?

High resistant fetal-placenta circulation

Fetal umbilical vascular (A/V),

fetal ductus venosus

Increase oxygen supply

Fetal umbilical artery (velocity),

fetal cardiac size

Control oxygen distribution

Redistribution fetal circulation

Fetal biometric, amniotic fluid index,

fetal cerebral media artery

Reduce oxygen consumption

Heart rate reactivity (CTG/ vibroaccoustic test), fetal behavior

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Strategy
Alert

Basic
scanning

Advance
scanning

Maternal condition

Fetal biometric

Detail fetal organs

Fetal movement counting

Amniotic fluid index

Circulation:

Heart rate monitoring

Fetal behavior

Maternal-placenta

Placental condition

Intra-placenta

NST/ CST

Fetal-placenta
Fetus redistribution
Invasive fetal testing

The more data you have, the more focus and accurate your analysis
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Fetal movement counting

Technique

Period

Normal
frequent

Sadovsky, 1977 1 hour

Rayburn, 1982

2 hour

Pearson, 1976

12 hour

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Harper 1981

24 hour

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Simple and practical

Very subjective and have various method
Need maternal focus and experience
For alertness only: if abnormal, need further fetal
assessment

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Cardiotocography
Component

Criteria for interpretation

! Basic frequency

! Satisfying or not

! Variability

! Reassuring

! Acceleration

! Non reassuring

deceleration
! Fetal movement

! Suspicious
! Ominous

! Uterine contraction

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Satisfying or not

Satisfying

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Not satisfying

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Reassuring pattern
(normal reactive fetal)

Reactive fetal

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Early deceleration
Head compression

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Non-reassuring pattern
Be aware

Fetal tachycardia

Fetal bradycardia

Saltatory variability
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Non reassuring pattern

Be aware

Late decelerations with preserved beat-to-beat

variability
Placenta insufficiency

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Variable decelerations
Cord compression

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Suspicious pattern
Be aware, this is temporary condition
before it will be reassuring or non
reassuring pattern

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Ominous pattern
You have to do something immediately
to safe the fetus life

Loss of beat-to-beat variability

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Sinusoidal pattern

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Ominous pattern
You have to do something immediately
to safe the fetus life

Persistent late decelerations with loss

of beat-to-beat variability

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Variable decelerations associated with loss

of beat-to-beat variability

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Cardiotocography
! Non stress test (NST)
! Stimulation NST (vibro-accoustic test)
! Contraction stress test (CST)

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Contraction stress test (CST)

! To reassure: fetal-placental oxygen reserve
! The contraction stress test is designed to assess fetal response from

the induced stress of uterine contractions and relative

uteroplacental insufficiency.
! Uncommonly used at present
! The worse fetal condition probably happen when fetal already have

hypoxia or previous placenta insufficiency: asymmetric IUGR, fetal

anemia, severe oligohydramnion, post term.
! Some contraindication: PROM, previous SC, incompetent cervix
! Need rapid response facility.

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Stimulation NST
Vibro-accoustic test (VAS)
! VAS reduced the incidence of non-reactive antenatal

cardiotocography test and reduced the overall mean

cardiotocography testing time (Cochrane review 2001)
! When combined with other test (biophysics profile), it could

replace CST

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Fetal Biometric

Diameter biparietal (DBP)

Head circumference (HC)

Abdominal
circumference (AC)

Fetal weight

Femur length (FL)

Fetal proportion

Symmetric or asymmetric IUGR

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Asymmetric IUGR
Chronic hypoxia

There is wide discrepancy between HC and AC (HC>> AC)

Femur length is normal or little bit smaller
Most of the case have other sign of fetal hypoperfusion such
oligohydramnion and reduce fetal activities
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Amniotic fluid index

Amniotic fluid volume

Oligohydramnios

AFI value
! 5 cm

Borderline

5.1 ! 8.0 cm

Normal

8.1 ! 18.0 cm
" 18 cm

Polyhydramnios

Phelan, 1987
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Meta analysis about AFI and perinatal outcome

(Am J Obstet Gynecol 1999;181:1473-8.)

An antepartum or intrapartum amniotic fluid index of <5.0 cm is

associated with a significantly increased risk of cesarean delivery
for fetal distress and a low Apgar score at 5 minutes.

Do not value AFI by qualitative such as normal, lack or plenty.

Value it with quantitative such as: AFI: 5.0
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Caseosa vernic or meconium ?

simple amniocentesis could prove that

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Fetal Behavior
Fetal tone: flexion-extension

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Fetal Behavior
Fetal gross movement: general activities

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Fetal Behavior
Fetal breathing movement:
diaphragm muscle activities

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Biophysics profile timeline

Embryogenesis

Heart beat

Fetal tone

5.5 weeks
Medulla

8 weeks
Subcortical area

Fetal gross
movement
9 weeks
Cortex

Fetal
breathing
movement

Fetal
heart beat
reactivity

21 weeks
Ventral surface
of 4th ventricle

28 weeks
Posterior
hypothalamus

Hypoxia

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Compensated

Increased cardiac contractility

Cardiomegaly

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Low renal perfusion

Low bladder fulfillment

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Placental condition
Grading placenta show portion of
calcification that reflected fibrin deposit.
Even in general theres no relation with
placental function but it can be a
significant sign if there are other placenta
insufficient sign

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Circulation
Doppler evaluation
PS

ED
M= (S+D)/2

Index
Systolic-Diastolic (S/D)

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Formula
S/D

Resistance Index (RI)

(S-D)/S

Pulsatile Index (PI)

(S-D)/M
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Doppler evaluation
A. umbilical

Normal

Increased

Absent end diastolic

Reverse end diastolic

Increase vascular resistance could happen on preeclampsia

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Doppler evaluation
A. uterine
Reflect:
Maternal-placenta circulation
(Utero-placental circulation)
Good predictor for maternal hypertension
Normal

Normal notching on
Non pregnant women
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Notching: resistance "

Pregnant > 24 weeks

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Doppler evaluation
A. Cerebri media
RI (resistance index)
normal

low RI

Normal MCA: Vasoconstriction (high RI).

Vasodilation (low RI) show a brain sparring
effect condition

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Doppler evaluation
Other vessels
Ductus venosus

Umbilical vein
normal v. umbilikalis

normal duktus venosus

reverse end diastolic

Show high resistance on the right heart
Low oxygenation to the heart
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The meaning of high vascular resistance

Heart
PUMP

! High distal organ resistant

! High cardiac contractility
! Vascular resistant :
! Vasoconstriction
! Low elasticity
! Obstruction (true knot)

! High viscosity intra vascular material

! Close to distal organ
Placenta
TARGET
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Scoring system
Biophysics profile score (Manning, 1980)
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Interpretations of BPS
Score BPS

Interpretation

Predicted
PMN/1000

10/10
8/8

Recommended
management
No acute
intervention

No fetal asphyxia

< 1/1000

8/10
Oligo

Chronic fetal
compromise

89/1000

6/10
AFI normal

Equivocal test, asphyxia

is not excluded

4/10

Acute or acute on
chronic asphyxia

91/1000

Deliver - close
monitoring

2/10

Acute asphyxia
chronic decompensation

125/1000

SC deliver for
fetal indication

0/10

Severe acute asphyxia

600/1000

SC deliver
immediately

8/10
AFI normal

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Deliver at any
viable gestation

depends on progression Repeat test

61/1000
immediately

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Scoring system: BPS modification

Fungsi dinamik janin plasenta (Wiknjosastro, 1998)
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Score < 5 : suspected fetal metabolic acidosis and suggest for SC deliver
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Preeclampsia
Conservative vs termination
Termination of pregnancy
! Maternal life threated
! Aterm or near aterm ( 35 weeks or more)
! Low BPS (4/10 or less)
! Extreme fetal Assessment result:
! Ominous CTG
! Severe oligohydramnion
! Absent or reverse end diastolic umbilical artery

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Check list system

Abnormalities fetal assessment for further management
Variable

No

Abnormal Fetal tone

Abnormal gross movement

Abnormal breathing movement

Ominous pattern CTG

Yes

Absent or reversed end diastolic umbilical artery

Non reassuring CTG

Unknown

!
!

Oligohydramnion

Asymmetrical IUGR

Brain sparring effect (Low RI MCA)

Notching maternal uterine artery

High resistance umbilical artery

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Which is the best system ?

! Not one system is 100 % accurate to predict
! More data you have, more accurate
! Different center, different situation/ condition,

different treatment.
(remember: there are wide variation condition on
preeclampsia, both for mother or fetus)

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