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Fetal assessment

Dr. Khalid Khadawardi, MBBS. ARDMS. FRCS


Maternal-Fetal Medicine Division
OBS-GYN Department
University of Umm-Alqura
khadawardi@hotmail.com
kkhadawardi@imc.med.sa
Objectives
 Indications
 Modility
 Timing
 Managment
INDICATIONS

EVERY ONE
INDICATIONS
 Anypatient at risk for developing decreased
utero-placental function, including:
 Maternal Disease
 Diabetes
 Chronic Hypertension
 Pregnancy-induced Hypertension, preeclampsia
 Renal disease
 Collagen dieases
 Cardiac disease
 Thyroid disease
 Significant hematologic disease (severe anemia, etc.)
 Thrid-trimester vaginal bleeding
INDICATIONS
 History of poor obstetric outcome
 Post-dates pregnancy
 Fetal indications
 Suspected intrauterine growth restriction (IUGR)
 Suspected decrease in fetal movement
 Irregular or abnormal FHR by auscultation
 Suspected Rh sensitization
 Multiple gestation with suspected IUGR or discordant
growth
 Premature rupture of membranes
 Oligohydramnios/Polyhydramnios
Modility
 Maternal kick counts
 EFM
 Fetal blood sampling
 Fetal Biophysical Profile
 ST-wave forms
 Doppler US
MATERNAL KICK COUNTS
 Description
 Recording the mother’s perception of fetal
activity. This is the oldest and most
inexpensive method of evaluating fetal well-
being.
MATERNAL KICK COUNTS
 Interpretation
Definitions of decreased fetal movement
include:
 >10 movements in 12 hours
 3 or fewer movements per hour
 Management
 Normal kick count: repeat recordings daily
 Decreased or absent fetal movement:
proceed with immediate evaluation and
further testing (NST or BPP)
Fetoscopes
Determinants of FHR
 Intrinsic
beating frequency
 Action of nerves and hormones on the
heart
EFM: Problems and Realities

• Electronic Intra-partum FHR Monitoring is now


considered mandatory for high-risk pregnancies
• Difficulties with interpretation include over confidence
and not-only difference in opinion between practitioners
but, also when the same practitioner examines the NST
twice
• Increases CS rates (RR 1.41)
• Increases operative vaginal delivery (RR 1.20)
• No change in incidence of Cerebral Palsy
• Reduction in Neonatal seizures rates (RR 0.51)
• No difference in APGAR scores
• ?Efficacy
EFM- Facts

• Reliability of interpretation- 50-75% are


false positive
• False positive Dx reduces to 10% with FBS
• FBS 93% sensitivity, 6% false positive
EFM- Basic Features
EFM- Basic Features

1. Baseline FHR – average FHR excluding accels and


decels (110-160 bpm)
 Tachycardia
 Bradycardia
1. Baseline Variability - minor fluctuations of baseline FHR
at 3-5 cycles pm between contractions
 Absent (no amplitude range)
 Minimal (< 5bpm)
 Moderate (6-25 bpm)
 Marked (> 25 bpm)
Baseline variability CTG

Minimal

6
Moderate

Marked
EFM - Accelerations

 Transient increase in FHR of 15 bpm x


15 sec
EFM - Decelerations

 Transient slowing of FHR below the baseline


level of more than 15 bpm x > 15 sec
 Early
 Variable
 Late
 Prolonged
Late Decelerations
Variable Decelerations
Prolonged Deceleration
Sinusoidal pattern
EFM-Summary
 Normal
 Non-reassuring vs reassuring

“Holy milk bottle, I’ve been cloned”


Fetal Blood Sampling
 Cordocentesis

 Fetal scalp pH.


Fetal Blood Sampling
 information on the acid base balance
 Has 6%-20% false negative (i.e., normal)
 8-10% false positive (i.e., low values)
 Why and when to do:
 Persistent Abnormal CTG after reversible factors have been
corrected
 Persistent late decels and 2 abnormal other features e.g
baseline tachycardia or reduced B-B variability or just difficult to
interpret the CTG
 ROM, accessible and well applied Cx (> 3 cm)
 Sterile environment, good light and equipment
 Good analgesia
FBS - Cord pH
 FBS-Arterial
 Normal-7.25-7.35
 Less than 7.20-significant asphyxia
 Imminent delivery
 Valuesbetween 7.2 and 7.24 need further
evaluation
 should be repeated in 30 mim
FBS Contraindications
Fetal
Premature – < 34 wks
Active Herpes
Known HIV,Hep B/C positive status
Thrombocytopenia
Maternal
Unfavourable Cx
Mobile PP
Malpresentation(face etc) uncertain??
Placenta Praevia or APH
Sepsis
FBS-Sampling errors
 Between decelerations if possible
 Avoid Excess pressure on head: reduces
perfusion
 Do not sample on the caput
 Failure of scalp to bleed – due to
peripheral shut down
Fetal US scan
 Structural scan
 Growth assessment
 Placenta location
 Morphology

 Functional scan
 BPP
 Doppler
BIOPHYSICAL PROFILE
 BPP is a physical examination of the fetus utilizing real-
time ultrasound in combination with the NST

 BPP is based on assessment of five biophysical


variables which include:
1. Fetal breathing movements (FBM)
2. Gross body fetal movement (FM)
3. Fetal tone (FT)
4. Amniotic fluid volume (AFV)
5. Nonstress test (NST)
BIOPHYSICAL PROFILE
 The variables are scored according to the fixed
criteria and assigned a score of 2 if normal and 0
if abnormal.
 The NST portion of the BPP may be excluded.
Its absence does not alter test accuracy but
does improve its efficiency.
 The duration of real-time observation is
extended until normal criteria have been met for
each biophysical variable or a maximum period
of 30 minutes has elapsed.
BIOPHYSICAL NORMAL (SCORE =2) ABNORMAL (SCORE =0)
VARIABLE
FETAL BREATHING At least 1 episode of at least 30 Absent FBM or episode of <30
MOVEMENTS (FBM) seconds in duration in 30 seconds in 30 mintues
minute observation

GROSS BODY At least 3 discrete body/limb 2 or fewer episodes of


MOVEMENTS (FM) movements in 30 mm (episodes body/limb movements in
of continuous movement 30 mm
considered as single
movement)

FETAL TONE At leat 1 episode of active Either slow extension with


extension with return to flexion return to partial flexion or
of fetal limb(s) or trunk. movement of limb in full
Opening and closing of hand extension or absent fetal
considered normal tone movement

AMNIOTIC FLUID At least 1 pocket of AF that Either no AF pockets or a


VOLUME (AFV) measures at least 2 cm in 2 pocket < 2 cm in two
perpendicular planes (or AFI perpendicular planes (or AFI,
>5cm) <5cm)
NONSTRESS TEST At least 2 episodes of FHR Less than 2 episodes of
(NSI) acceleration of> 15 beats/mm acceleration of FHR or
and of at least 15 sec duration acceleration of< 15 beats/mm in
associated with fetal movement 10 mm
in 10 mm
Perinatal Mortality and the Biophysical Profile
Score

Score Perinatal Mortality/1000

8-10 1.86

6 9.76

4 26.3

2 94.0

0 285.7
Biophysical profile
Amniotic fluid volume- oligo is frequently associated
with IUGR (↓ blood volume ,↓ renal blood flow, ↓ urine
output)
Perinatal morbidity ↑ 10 times if oligo present.
IUFD in 5 – 10 % if oligo present.
IUFD with Bpp 8/8 is 0.7 in 1000 birth. Vs 40% if score
is 0/8..
False –ve is < than 1 / 1000.
ST-wave forms
Doppler Ultrasound
• Arterier system:
• Middle cerebral artery
• Aorta
• Umbilical artery
• Uterine artery
• Venus system:
• IVC
• Ductus venosus
• Umbilical ven
• Tricasped valve
MCA
Fetal Aorta
Umbilical artery
Uterine artery
DUCTUS VENOSUM
Umblical Vein
FGR
Timeline for Fetal distres

Abnormal arterial
2-8W Doppler

Abnormal venous
Doppler
1-4W

Low BPP
1-2D Score

Non reasuring
12-24H NST
Take-home points
Fetal health surveillance aims at
improving fetal outcomes by
identifying those with hypoxic
acidemia & intervening while it is still
reversible
Take-home points
 The reliability, validity, & efficacy of EFM
remain contentious
 Fetal biometry and arterial Doppler the
early sign
 Venous Doppler, FHR analysis, and the
biophysical profile represent the later
stages(commonly associated with fetal
acidosis)