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Fetal maturity

and wellbeing
assessment.
Dr. Clayon Kelly

Estimated date of delivery is 280 days


from onset of LMP and 266 days from
date of conception
Fertilization of an oocyte in vivo cannot
be detected by laboratory or image
method, which occurs within 24hrs of
ovulation.
Only 4% of women delivers on their
EDD

Clinical assessment
Naegeles Rule
Most common means of pregnancy
dating
EDD is calculated by counting back 3
months and adding 7 days,
LMP = Feb 20/ EDD = Nov 27

Assumptions The patient has a 28 day cycle


Fertilization occurs on day 14

Naegeles Rule
Limitations
Many women do not have a 28 day cycle
(follicular phase is variable)
Fertile window is more than 1 day (which is
not necessarily on day 14)
There are variations in time from fertilization
to implantation
Many women are uncertain of LMP
Early pregnancy bleeding or recent OCP usage
can lead to incorrect assumption of date of
ovulation

Clinical asssessment
Uterine size
Uterus remains a pelvic organ until 12
weeks gestation, where it is just above
the symphysis pubis
At 16 weeks- midway between
symphysis and umbilicus
At 20 weeks at umbilicus
After 20 weeks the SFH in cm should
correlate with week of gestation

Uterine size
Limitations
Pelvic mass (leiomyoma)
Obesity
Retroverted uterus

Ultrasonography has advanced obstetric


practice by enabling with relative detail
assessment of the fetus.
With an accurate estimate of gestational age
when performed in the first half of pregnancy.
This is invaluable because most obstetrical
management decisions are strongly
influenced by fetal development, which
correlates with fetal age.

Gestational age calculations are based upon


biometric measurements, the optimal time to
obtain an estimate of gestational age is during
the first trimester when biologic variation in size
from fetus to fetus is minimal.
In the earliest stages of pregnancy, trans-vaginal
ultrasound generally provides clear and accurate
images, therefore, TVS is typically used for first
trimester evaluation of the gestational sac, yolk
sac, and developing embryo.

As the uterus grows out of the pelvis


into the mid and upper abdomen and
the fetus gets bigger, trans-abdominal
ultrasound usually provides better
visualization of the pregnancy.

The gestational sac is the first sonographic


sign of an intrauterine pregnancy and
appears as a small fluid filled sac-like
structure within the uterus.
If there are no distinct structures within
the gestational sac, then initial dating
measurements are based on sac diameter.
Gestational age based upon gestational
sac measurements can be calculated in
several ways.

Gestational sac measurement is less


accurate later in pregnancy when the
fetal pole can be identified, i.e. if a CRL
can be obtained or sac size is > 14 mm
Gestational sac size is accurate to +/5 to 7 days

Yolk sac is the first anatomic structure


in the gestational sac and provides
confirmation of intrauterine pregnancy.
But yolk sac diameter correlates poorly
with gestational age, hence not used
for dating

Crown rump length


The crown-rump length (CRL) is the standard biometric
measurement of the embryo in the first trimester.
By definition, the crown-rump length is the longest
straight-line measurement of the embryo measured
from the outer margin of the cephalic pole to the rump.
Standard practice for determining gestational age is to
take the mean of three CRL measurements. When CRL
is measured between seven and 10 weeks, this
method is accurate within three days. However,
accuracy wanes as the gestation progresses.

Estimation of gestational age by CRL between


10 to 14 weeks is accurate within 5 days,
and expands to within 8.4 days at 15
weeks.
CRL is most accurate at 7 to 10 days (+/- 3
days)
This variation has been attributed to normal
biological differences in embryologic
development and variations in anatomical
positioning of the fetal head and torso.

Tables have been formulated to estimate


gestational age for each numeric
measurement of CRL up to 12 cm.
It is advice that CRL > 84mm, biparietal
diameter (BPD) should be done instead
for gestational age assessment
NB. If the embro is seen but too small to
measure , detection of cardiac activity =
gestational age of 5.5 to 6 weeks

The four standard biometric parameters commonly


used to estimate gestational age and/or fetal weight
in the second and third trimesters are: biparietal
diameter (BPD), head circumference (HC), abdominal
circumference (AC), and femur length (FL).
They are typically obtained by transabdominal
ultrasound examination. All four of these
measurements are highly reproducible and can
predict gestational age within 7 days when
measured between 14 and 20 weeks of gestation.
Unfortunately, accuracy diminishes as the gestation
progresses beyond this period.

By the mid to late third trimester, the


margin of error is three to four weeks.
This significant variation is likely due to
a large normal biological variation in
fetal shape and growth near term.

There are several signs suggestive of fetal


maturity that can be observed
sonographically and correlated with
gestational age when an early ultrasound
examination has not been done or
menstrual dates are unknown or uncertain.
As an example, the femoral epiphyseal and
proximal tibial ossification centers are well
visualized by 32 and 35 weeks gestational
age, respectively..

The proximal humeral epiphysis also


appears in the late third trimester and
correlates with fetal lung maturity and
gestational age.
Identification of such landmarks help
to establish fetal maturity in late
pregnancy

Fetal maturity
Two types of tests are used to
determine pulmonary maturity: (1)
biochemical tests measure the
concentration of particular
components of pulmonary surfactant
and (2) biophysical tests evaluate the
surface-active effects of these
phospholipids.

Biochemical Tests
Lecithin/sphingomyelin ratio The
lecithin/sphingomyelin (L/S) ratio for assessment of fetal
pulmonary maturity is based upon the observation that
there is outward flow of pulmonary secretions from the
lungs into the amniotic fluid.
This process changes the phospholipid composition of
amniotic fluid, thereby enabling indirect assessment of
fetal lung maturity through evaluation of this fluid. The
concentrations of lecithin and sphingomyelin in amniotic
fluid are approximately equal until 32 to 33 weeks of
gestation, at which time the concentration of lecithin
begins to increase significantly while the sphingomyelin
concentration remains about the same.

A threshold value for prediction of lung maturity


should be calculated in individual centers by
correlation with clinical outcome, as the variation
within and between laboratories can be
considerable. Empirically, the risk of respiratory
distress syndrome (RDS) is exceedingly low when
the L/S ratio is greater than 2.0.
The presence of blood or meconium can interfere
with test interpretation. Bloody samples give false
information, for example, due to the presence of
sphingomyelin in blood. Thus, the ratio derived
would be artificially low.

Phosphatidylglycerol Phosphatidylglycerol
(PG) is a minor constituent of surfactant. It begins
to increase appreciably in amniotic fluid several
weeks after the rise in lecithin.
Because PG enhances the spread of phospholipids
on the alveoli, its presence indicates an advanced
state of fetal lung development and function. It may
be reported qualitatively as positive or negative,
where positive represents an exceedingly low risk
of RDS, or in a quantitative fashion, in which a
value 0.3 is associated with a minimal rate of
respiratory distress.

Lamellar body counts


Direct measurements of surfactant
production of type II pneumocytes

Biophysical test
The foam stability index (FSI) is a rapid predictor of
fetal lung maturity based upon the ability of
surfactant to generate stable foam in the presence of
ethanol.
Ethanol is added to a sample of amniotic fluid to
eliminate the effects of non-surfactant factors on
foam formation. The mixture is then shaken and will
demonstrate generation of a stable ring of foam if
surfactant is present.
The foam stability index (FSI) is calculated by utilizing
serial dilutions of ethanol to quantitate the amount of
surfactant present.

Amniotic fluid samples should not be


collected in silicone tubes when this test is
planned, as the silicone will produce "false
foam". The discriminating value indicative
of lung maturity is usually set at 47.
A positive result virtually excludes the risk
of RDS, however a negative test often
occurs in the presence of mature lungs. The
presence of blood or meconium interferes
with results of the FSI.

Optical density at 650nm


An indirect measurement of lamellar
bodies, can be done by using optical
density of amniotic fluid at wavelength
of 650nm.
Increasing opalescence is due to
increasing lamellar bodies
A optical density reading of >= 0.15 is
an indicator of lung maturity

Fetal wellbeing

WHY ASSESS THE


FETUS?
There is a baseline perinatal mortality rate
in all populations

Some deaths inevitable (e.g. renal


agenesis)

Some preventable (certain cases of IUGR 2o


severe PE)

WHY ASSESS THE


FETUS?
Fetal surveillance is aimed at finding
the pregnancies which can be altered
in a positive manner

WHAT ARE WE
ASSESSING FOR?
As levels of oxygen in the brain fall,
various areas of the brain and spinal
cord are increasingly inhibited
This results in progressive loss of
fetal breathing movements, gross
fetal movements and fetal tone
Persistent Hypoxia fetal demise

ADVERSE EFFECTS
OF HYPOXIA
Fetal Outcomes

Neonatal Outcomes

Stillbirth

Mortality

Metabolic acidosis
at birth

Metabolic acidosis
Hypoxic renal damage
Necrotizing
enterocolitis
Intracranial
haemorrhage
Seizures
Cerebral palsy

WHICH TO ASSESS?
Small for gestational age fetus
Decreased fetal movement
Postdates pregnancy
Pre-eclampsia/chronic hypertension
Pre-pregnancy diabetes
Insulin requiring gestational diabetes
Preterm premature rupture of membranes
Chronic (stable) abruption
Rhesus isoimmunization

HOW TO ASSESS
Assessment of fetal condition can be performed by
various means

Maternal assesment of fetal activity,


Cardiotocographic monitoring,
Sonographic assessment of fetal activity and
amniotic fluid volume, and
Doppler velocimetry

fetal movements may be consistently


appreciated by the mother several
weeks before the heart can be
clinically auscultated.
The use of fetal "kick" counts as a
primary means of fetal surveillance is
controversial since this procedure has
not been standardized nor proven
effective

Easy to perform
Inexpensive
Convenient
Keeps the patient aware of her fetus's
usual behavioral pattern

2 types
Sadovsky technique
Mother rest after eating for 1 hour and
fetal activity checked (5- 10)

The Cardiff count-to-ten chart


Record fetal movements during the
course of her usual daily activity. A
period of 12 hours without at least 10
perceived movements is considered a
warning signal.

Fetal heart
auscultation
This may be done sonographically from anytime
after six weeks; via hand help Doppler from
early in the second trimester; and by
auscultation after 26 to 28 weeks.
The normal fetal heart range is 110-160 beats
per minute; the baseline rate tends to fall as
pregnancy progresses. Regular auscultation
which reveals a regular, normal rate and
rhythm is encouraging. Abnormal heart rhythms
may include tachycardias, bradycardias, or
irregularity in the heart rate.

These may indicate general fetal


compromise, or more specific
cardiogenic pathology. Absence of fetal
heart tones may be indicative of intrauterine demise

Electronic fetal heart


monitoring
The electronic fetal monitor determines the FHR
and continuously records it in graphical form.
NST- FHR accelerations, spontaneous or provoked
have been shown to be a good predictor of normal
autonomic function and absence of acidosis and
neurologic depression.
CST- Is based on the fetal response to a transient
reduction in fetal oxygen delivery during uterine
contractions. If the fetus becomes hypoxemic, the
fetal chemoreceptors, baroreceptors, sympathetic
and parasympathetic influences respond by slowing
FHR which may manifest as a late deceleration

NST

Internal monitoring Internal measurement of


FHR is an invasive procedure. A bipolar spiral
electrode is inserted transcervically to penetrate the
fetal scalp and a second reference electrode is placed
upon the maternal thigh to eliminate electrical
interference.
The internal electrode detects the fetal ECG and
calculates the fetal heart rate based upon the interval
between R waves. This signal is very clear and
provides accurate measurement of beat-to-beat and
baseline variability. Artifact is kept to a minimum, and
there is little need for autocorrelation.

Ultrasound
Sonographic evaluation using the biophysical
profile or Doppler velocimetry are widely used for
antepartum evaluation. However, neither test is
useful for intrapartum fetal monitoring
Doppler waveform analysis of the umbilical artery
is used extensively for assessing downstream
resistance to flow. The value of this technique is
primarily for monitoring growth restricted fetuses.
It is not recommended for general fetal
surveillance

The biophysical profile (BPP) typically consists of


electronic fetal heart rate evaluation combined
with sonographically assessed parameters of fetal
well being including fetal breathing movements,
gross fetal movements, fetal tone, and amniotic
fluid volume.
Each parameter is scored either 0 or 2; therefore,
the total BPP score will be 0, 2, 4, 6, or 8. A
biophysical profile of 8/8 has a very high negative
predictive value for fetal death; i.e. if it is 8/8 the
fetus has greater than a 99.5% chance of not
dying within the next week..

A score of 6/8 suggests that it needs


repeating within the next six to eight
hours, as it is an intermediate score. A
score of 4 suggests significant fetal
hypoxia; a score of 2 or 0 suggests
impending fetal demise. Any score of 4
or less mandates urgent delivery

Result

SONOGRAPHIC
ASESSMENT
Asphyxia Asphyxia Risk of
Treatment
Risk

Death
(per
1000/wk)

10/10

None

0.565

None

8/10

None

0.565

None

8/8

None

0.565

None

8/10 (AFI)

Chronic

5-10

20-30

>37, deliver
<37, serial
testing

6/10

? Acute

50

>37, deliver
<37, rpt. In 24
hrs: deliver if
persistent

Result

SONOGRAPHIC
ASESSMENT
Asphyxia Asphyxia Risk of
Treatment
Risk

Death (per
1000/wk)

6/10 (AFI)

Chronic +
acute

>10

>50

>34, deliver
<34, test od

4/10

Acute

36

115

>34, deliver
<34, test od

4/10 (AFI)

Acute +
chronic

>36

>115

>28, deliver

2/10

Acute

73

220

>28, deliver

0/10

Severe

100

1000

>28, deliver

SONOGRAPHIC
ASESSMENT
Score of 8 or 10 good outcome, predictive for one
week
Score of 6 equivocal; repeat and reassess within
24 hrs.
Score of 4 or less needs delivery; timing according
to gestational age and/or severity of score

Excellent negative predictive value


Poor positive predictive value

DOPPLER STUDIES
The Doppler effect is a change in the
frequency of a wave, resulting from
motion of the wave source or receiver,
or in the case of a reflected wave,
motion of the reflector

In medicine, Doppler US is used to


detect and measure blood flow, and
the major reflector is the red blood cell

Normal Umb. Art.


Doppler

Abnormal Umb. Art.


Doppler

DOPPLER STUDIES
Umbilical artery Doppler studies should
not be used as a screening tool in the
general population

At present there appears to be a role for


umbilical artery Doppler assessment in
pregnancies complicated by growth
restriction or pregnancy associated
hypertension/pre-eclampsia

DOPPLER STUDIES
Other high risk pregnancies may also
benefit

For instance, middle cerebral artery


doppler for assessment of severe
anaemia in rhesus isoimmunization

DOPPLER STUDIES
Intervention based on the identification
of abnormal umbilical artery waveform
patterns has reduced the incidence of
perinatal death by 38% in pregnancies
at risk

DOPPLER STUDIES
ADVANTAGES
Relatively low cost
Equipment generally available

Documented to make a positive impact on

perinatal mortality, in appropriate subgroups of patients

DOPPLER STUDIES
DISADVANTAGES
Assessment requires some skill
Assessment is sometimes highly user
dependent
Not appropriate in labour
Limited application

Biochemical
Capillary blood collected from the fetal
scalp usually correlates well with
arterial values. However, scalp edema
can result in erroneous results. A scalp
pH value of <7.20 has traditionally
been used to represent the critical
value for identifying fetal acidosis.

BIOCHEMICAL MONITORING

The accuracy of intermittent fetal scalp


pH assessment for predicting fetal
stress with subsequent neurologic
sequelae has been questioned

It is no longer used in many institutions,


although its use can result in fewer
cesarean deliveries performed for the
indication of non-reassuring fetal status.

THANK YOU