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Antepartum
assessment of
fetal well being
Presented by Dr. Pankaj sharma
igmc shimla
dr.pankajigmc789618@gmail.com
1
HISTORY
• Fetal heart sounds first detected by
Marsac in the 1600A.D.
• Can be used to determine fetal well
being was first proposed by Killian in
the 1600’s.
• Mayor and Kergaradec described the
method of auscultating fetal heart
sounds by placing the ear next to the
maternal abdomen. .
• In 1893, Von Winkel established
criteria for fetal distress that
remained unchanged until the advent
of electronic fetal monitoring 2
INTRODUCTION
• ANTENATAL FETAL SURVEILLANCE IS
ASSESSMENT OF FETAL WELL BEING IN
ANTEPARTUM PERIOD TO ENSURE
DELIVERY OF HEALTHY NEONATE.
Two main objectives are:-
 Early detection of fetuses at risk
to prevent perinatal mortality and
morbidity.
 Find out normal fetuses and avoid
unwarranted interventions.
3
ANTEPARTUM FETAL
ASSESSMENT
• METHODS:-
• 1a CLINICAL ASSESSMENT
• Weight gain
• Fundal height
• Abdominal girth
• Auscultation of fetal heart
• 1b fetal movement count by mother
• 2.ultrasound for fetal parameters
• 3.biochemical tests
• 4.NST
• 5.VAST
• 6.CST 4
• 7.Nipple stimulation test
• 8.biophysical profile
• 9.doppler
• 10.fetal lung maturation test
• 11.placental grading
5
INDICATIONS
• MATERNAL
• FETAL
• PREGNANCY RELATED
• MATERNAL
• Hypertension
• Diabetes
• Heart disease
• Chronic renal disease
• Sever anemia
• APLA
• Acute illnesses 6
Fetal
• Fetal growth restriction
• Rh isoimmunisation
• Fetal cardiac arrythmias
• Fetal infections
7
PREGNANCY RELATED
• Multiple pregnancy
• Gestational hypertension
• Preeclampsia
• Decreased fetal movement
• Abnormal placentation
• Placental abruption
• Amniotic fluid disorders
• PROM
• GDM
• Previous unexplained still birth
• ICP
• Post term pregnancy 8
WHEN TO START?
• Depends up on factors like:-
• Past history of adverse outcome
• Severity of maternal and fetal
conditions
• Generally Monitoring is recommended
when estimated fetal maturity is
sufficient to expect a reasonable
chance of survival should intervention be
necessary.
9
CLINICAL ASSESSMENT
• WEIGHT GAIN
10
Recommended Ranges of Weight Gain
During Singleton Gestations Stratified by
Pre pregnancy Body Mass Index
Category BMI Wt. in kgs
kg
Low 19.8 12.5–18
Normal 19.8–26 11.5–16
High 26–29 7–11.5
Obese 29 7
(Williams 23rd ed.)
Symphysio-fundal height
• Measured from superior border of
pubis symphysis to fundus
• From 24th wks of gestation
corresponds to period of gestation .
• Difference of 3-4 cms acceptable
• below 10th percentile or difference
of >4cms suggests IUGR
• positive predictive value of60%
negative predictive value of 76.8%
11
Abdominal girth
• Measured at lower border of
umbilicus.
• Increases by 2.5cm per week after
30wks.
• 95-100cms at term.
• Static or falling values alarming sign.
12
Fetal movement count
• Cardiff” count 10” technique
• Daily fetal movement count
• Perception of three movement in
30 minutes.
• Sadovsky’s “movement alarm
signal”fewer than three
movements an hour for 2
consecutive days.
GABBE 6TH ED.
13
Fetal movement count
• Fetus spends 10% of its time making
gross fetal body movements
• 30 such movements made each hour.
• Periods of active fetal body
movement last about 40 minutes
• Quiet periods last about 20 minutes.
• Longest period without fetal
movements about 75 minutes.
• Mother appreciate 70% to 80% of
gross fetal movements.
• (GABBE 6TH ED.)
14
• Fetal movement peak between 9:00 PM and
1:00 AM.
• Time when maternal glucose levels are
falling.
• Holden and coworkers hypoglycemia
associated with increased fetal movement.
Fetal activity does not increase after meals
or after maternal glucose administration.
(GABBE 6TH ED.)
15
• Cochrane review of four trials in 2007
concluded that there is insufficient
evidence to recommend routine fetal
movement counting to prevent fetal death.
• positive predictive value of the maternal
perception of reduced FM for fetal
compromise 2% to 7%
• Despite these results, there may be some
advantages to this type of fetal
assessment.
16
Factors affecting maternal
perception of fetal movement
• Fetal and placental factors :-
• Placental location
• The length and type of fetal
movements
• Amniotic fluid volume (AFV)
• Maternal factors :-
• Parity, obesity.
• Psychological factors anxiety.
17
• Froen and associates, found in a
cohort of 1200 women instructed to
start their fetal movement count at
the first convenient time of the day
that the mean time to count to 10
was less than 10 minutes.
(GABBE 6TH ED.)
18
ULTRASOUND FOR FETAL
PARAMETERS
• HIGH RESOLUTION UTRASOUND
REVOLUTIONIZED PRENATAL DIAGNOSIS.
• CAN BE:-
• BASIC
• TARGETED
• BASIC:-(in early pregnancy)
• Done at 10-14wks and includes :-
• No. of fetuses
• Fetal life
• Placental localization
• Internal os diameter
• Cervical length 19
• Gestational age
• maternal pelvic masses
• Any gross anomaly like anencephaly,limb
reduction defects.
• Nuchal translucency(80% fetuses with 5%
false positive rates)
• Only in high risk patients
20
• CRL smaller than gestational age
chromalsomal anomalies
Absencence of nasal bone at 10-12wks
Down syndrome
NB+NT detection rate of 92% & false positive
rate of 3.5%
Dutta 7th ed.
21
2nd &3rd triemester
• Serial measurements of BPD,AC,HC,FL.
• HC/AC ratio exceeds 1 before 32wks.
• 1 bw 32to 34wks. After 34wk falls below 1.
• In symmetric IUGR remains normal.
• Ratio can identify 85% IUGR fetuses.
• FL/AC remains 22 at all gestational ages from
21wks to term. >23.5 suggest IUGR.
• AC remains single best parameter to detect
IUGR with positive predictive value of 50%.
• Trans cerebellar diameter in mm corresponds to
POG from 11wks – 32wks .
• (James 4th ed.)
22
AMNIOTIC FLUID VOLUME
• Single deepest pocket >2cm normal
• Or
• Amniotic fluid index 5-25cm. (five
quadrant technique.)
23
Targetted ultrasound
• Done in high risk patients
• In developed countries offered to all patients
• Transverse section for fetal head
• Shape and internal structures. BPD,HC Measured to
detect hydrocephalus,anencephaly
• Transverse and longitudinal views of abdomen to
rule out anomaliesofstomach,kidneys,bladder,ventral
wall.
• Transverse section of fetal thorax to four
chambered view of heart.
24
Four chambered view of heart
25
• Identify three long bones in each limb
and any achondroplasia is iooked for.
• Saggittal ,coronal and transverse views
taken to rule out spinabifida.
cephalic index
Biparietal diameter/occipitofrontal diameter
• Age-independent
• Identify dolichocephaly and brachycephaly.
26
Fetal ECHO
• Indications
Fetal risk factors
• Suspected cardiac anomaly on level I scan
• Nuchal thickening/lucency
• Diaphragmatic hernia
• Duodenal atresia
• Tracheoesophageal fistula
• Cystic hygroma
• Chromosomal abnormalities
• Twin–twin transfusion
• Acardiac twin
• Vein of Galen aneurysm
(Nadas' Pediatric Cardiology, 2nd ed.)
27
• Maternal risk factors •
• Congenital heart disease
• Exposure to teratogen
• Diabetes
• Maternal infections
Familial risk factors
• Trisomy 21 (Down)
• Marfan
• Noonan
• Tuberous sclerosis
• Velocardiofacial/DiGeorge
(Nadas' Pediatric Cardiology, 2nd ed).
28
• Historically optimal timing between 18
and 22 weeks’ gestation.
• moving into an era of early risk
assessment .
• fetal echocardiography late first and
early second trimesters
• A limited number of reports describe
the utility of transvaginal imaging
between 10 and 13 weeks.
(Ultrasound Clin 6 (2011) 47–56)
29
Non stress test
• Freeman first described the NST in 1975.
• Physiologic premise of the NST is that:-
Nonhypoxic fetus
stimulus
•
•
• accelerate its heart rate
30
Method
• Patient is placed in a lateral tilt position
• FHR and uterine activity are monitored with
an external transducer
• FHR is monitored for 20 minutes.
• For 40 minutes in some cases to compensates
for sleep cycles then called EXTENDED NST.
• In some cases when the fetus is not reactive,
acoustic stimulation by artificial larynx a
sound stimulus for 1 to 2 seconds.
31
INTERPRETATION
• Reactive NST presence of two accelerations
of 15bpm over base line for 15sec in a 20-
minute time period with or without fetal
movements.
• Nonreactive NST absence of two accelerations
in a 40-minute period with or without acoustic
stimulation over a 40-minute period.
32
WHEN TO START ?
• NST is not routinely started until 32-
weeks gestation.
• Up to 50% of NSTs reactive from 24-
to 28-weeks gestation.
• 85% from 28 to 32 weeks of gestation
• In up to 50% of NSTs variable
decelerations may be observed.
• If last for <30 seconds and <2 during a
20-minute period
NO fetal compromise 33
PREDICTIVE VALUE
• With a reactive NST, the chance for
fetal death within 1 week is 1.9 per
1,000, giving a negative predictive
value of 99.8% after correction for
lethal anomalies.
• Best senstivity and positive predictive
value for IUGR and Hypertensive
disorders -70%
• Reactive NST is reassuring.
• Nonreactive NST is nonspecific and
requires further evaluation.
(Pediatr Clin N Am 56 (2009) 489–
504)
34
• The false-positive rate is considerably
higher, ranging from 50% to more
than 90% in various studies.
• In high-risk pregnancies, the false-
negative rate associated with a weekly
NST may be unacceptably high.
• In these cases, increasing frequency
of the NST to twice weekly may be
considered.
• (GABBE 6TH ED.)
35
VIBROACOUSTIC
STIMULATION TEST
• Used as an adjunct to NST
• If NST non reactive even after 40min
then:-
• Continue CTG monitoring till 90min
OR
Perform BPP
OR
VAST
36
• Auditory brainstem response functional
at 26 to 28 weeks’ gestation.
• VAST increase the incidence of reactive
NSTs after 26 weeks’ gestation .
• Reduce the testing time.
• artificial larynx that generates sound
82 Db -100db with a frequency of 80
Hz.
37
• A stimulus for 3 seconds or less is
applied near the fetal head.
• If the NST remains nonreactive
• Stimulus is repeated at 1-minute
intervals up to three times.
• (GABBE 6TH ED.)
38
• VAST have shown a decreased incidence
of nonreactive NSTs from 13% to 14%
down to 6% to 9%.
• SAFETY
• Arulkumaran and associate found:-
“ intrauterine sound levels from VAST
were not hazardous to the fetal ear.”
• no long-term evidence of hearing loss in
children followed in the neonatal period
and up to 4 years of age.
• (GABBE 6TH ED.)
39
MANAGEMENT PROTOCOL
OF NST
NST for 20 min Reactive
Repeate after 1wk Or earlier if situation
demands
• If non reactive Extend to 40min
• Non reactive VAST Non
reactive BPP
40
BIOPHYSICAL PROFILE
• Thorough evaluation of fetal well-being .
• Potential to significantly reduce the
false-positive rate of the NST/CST.
• The BPP was initially described by
Manning and colleagues in 1980.
• Vintzileos and colleagues subsequently
proposed an alternative BPP scoring
system.
• Rationale:-Fetal biophysical activities
controlled by centers in the fetal brain
sensitive to varying degrees of hypoxia.
41
BPP SCORING( MANNING)
1. Movements Three or more gross body movements SCORE
• in a 30-minute period.
• Simultaneous trunk and limb 2
• movements count as a single
• Movement
• Fewer than 3 gross body movements 0
• in a 30-minute period
42
CONT.
SCORE
• 2. TONE At least one movement of a limb from
• a position of flexion to one of extension, 2
• with a rapid return to flexion.
• Fetal limb in extension with no return 0
• to flexion with movement
• 3.Breathing At least 30 seconds of sustained
• FBMs observed over a 30-minute period 2
• Fewer than 30 seconds of sustained
• FBMs observed over a 30-minute 0 43
Cont.
• SCORE
• 4.AFPAt least a single amniotic fluid pocket
• measuring 2 cm in 2 perpendicular planes 2
• No amniotic fluid pocket that 0
• measures at least 2 cm
• 2 perpendicular planes
• 5. NST reactive 2
• NST non reactive 0
44
45
Vintzileos Scoring
• Nonstress test
• Score 2 (NST 2): 5 or more FHR accelerations of at
least 15 beats per minutes (bpm) in amplitude and at
least 15-second duration associated with FMs in a 20-
minute period.
• Score 1 (NST 1): 2 to 4 accelerations of at least 15
bpm in amplitude and at least 15-second
• duration associated with FMs in a 20-minute period.
• Score 0 (NST 0): 1 or less acceleration in a 20-minute
period.
46
Fetal movements
• Score 2 (FM 2): at least 3 gross (trunk
and limbs) episodes of FMs within 30
minutes.
• Score 1 (FM 1): 1 or 2 FMs within 30
minutes.
• Score 0 (FM 0): absence of FMs within
30 minutes.
47
Fetal breathing movements
• Score 2 (FBM 2): at least 1 episode of fetal
breathing of at least 60-second duration
within a 30-minute observation period.
• Score 1 (FBM 1): at least 1 episode of fetal
breathing lasting 30 to 60 seconds within 30
• minutes.
• Score 0 (FBM 0): absence of fetal breathing
or breathing lasting less than 30 seconds
within 30 minutes.
48
Fetal tone
• Score 2 (FT 2): at least 1 episode of extension of
extremities with return to position of flexion and also 1
episode of extension of spine with return to position of
flexion.
• Score 1 (FT 1): at least 1 episode of extension of
extremities with return to position of flexion or 1
episode of extension of spine with return to flexion.
• Score 0 (FT 0): extremities in extension. FMs not
followed by return to flexion.
49
Amniotic fluid volume
• Score 2 (AF 2): fluid evident
throughout the uterine cavity. A
pocket that measures greater than 2
cm in vertical diameter.
• Score 1 (AF 1): a pocket that
measures less than 2 cm but more
than in vertical diameter.
• Score 0 (AF 0): crowding of fetal
small parts. Largest pocket less than
1 cm in vertical diameter.
50
Placental grading
• Score 2 (PL 2): placental grading 0, 1, or
2.
• Score 1 (PL 1): placenta posterior
difficult to evaluate.
• Score 0 (PL 0): placental grading 3.
Maximal score, 12; minimal score, 0.
• (Clin Perinatol 38 (2011) 47–64)
51
Technique
• Performance of an NST.
• For gestations less than 32 weeks,
the qualifying criteria for
accelerations are greater than 10
bpm, lasting at least 10 seconds.
• Real-time ultrasound
• The time required related to fetal
state, with an average of only 5 minutes
if the fetus is in a 2F state but over 25
minutes if it is in a 1F state.
52
MANAGEMENT PROTOCOL OF
BPP
• 10 Normal; low risk for chronic asphyxia Repeat testing
at weekly to twice-weekly intervals (IN HIGH RISK
CASES)
• 8 Normal; low risk for chronic asphyxia Repeat testing
at weekly to twice-weekly intervals If oligohydroamnios
deliver.
• 6 Suspect chronic asphyxia If ≥36-37 wk gestation or
<36 wk with positive testing for fetal pulmonary
maturity, consider delivery. Otherwise repeat with in
24hrs
• if <36 wk and/or fetal pulmonary maturity testing
negative, repeat biophysical profile in 4 to 6 hr.
• deliver if oligohydramnios is present
53
• 4 Suspect chronic asphyxia If ≥36 wk
gestation, deliver.
• if <32 wk gestation, repeat with in
24hrs. If repeat score <6 deliver if >6
observe.
• 0-2 Strongly suspect chronic asphyxia
Extend testing time to 120 min.
• if persistent score ≤4, deliver,
regardless of gestational age
•
54
PREDICTIVE VALUE OF BPP
• To summarize the results of multiple
studies, the false-negative rate of a
normal BPP is less than 0.1%, or
fewer than 1 fetal death per 1000
within 1 week of a normal BPP
55
56Clin Perinatol 38 (2011) 47–64)
• NST and FBM Has highest senstivity
• Fetal tone has highest specificity
57
MODIFIED BPP
• Attempt to simplify and reduce the
time.
• Focusing on the components of the
BPP most predictive of perinatal
outcome.
• Two parameters:-
• 1. NST indicator of present fetal
condition.
• 2. AFI /AFP a marker of long-term
status.
58
Predictive value
• Miller have demonstrated comparable
results of the mBPP to the full BPP.
• False-negative rate (or rate of fetal
death within 1 week of a normal
mBPP) of 0.8 per 1000.
• Modified BPP has a false-positive rate
comparable to the NST.
• But higher than the CST and full BPP.
• AFI or DVP under investigation.
(GABBE 6TH ED.) 59
• Chauhan and colleagues found that the AFI
led to more diagnoses of oligohydramnios and
a higher rate of intervention without
improving outcome.
60
Contraction Stress Test
CST/OCT first biophysical technique widely applied
for antepartum fetal surveillance.
Principle
uterine contractions
Reduction in blood flow to the intervillous space.
Inadequate placental respiratory reserve
Recurrent late decelerations in response to hypoxia.
61
TECHNIQUE
 Patient is placed in the semi-Fowler’s position at a
30- to 45-degree angle with a slight left tilt .
 Fetal heart rate and uterine contraction baseline is
determined.
 Blood pressure is recorded every 5 to 10 minutes to
detect maternal hypotension.
 oxytocin started @.5-1 miu /min.
 An adequate CST requires uterine contractions of
moderate intensity lasting about 40 to 45 seconds
with a frequency of three in 10 minutes.
62
INTERPRETATION
 Negative: No late or significant
variable decelerations
 Positive: Late decelerations with at
least 50% of contractions
 Suspicious: Intermittent late or
variable decelerations
 Hyperstimulation: Decelerations with
contractions longer than 90 seconds’
duration or 2-minute frequency
 Unsatisfactory: Fewer than three
contractions per 10 minutes or an
uninterpretable tracing
63
PREDICTIVE VALUE OF CST
• A negative CST good fetal outcome.
• incidence of perinatal death within 1
week of a negative CST (i.e., the
false-negative rate) to be less than 1
per 1000.
64
MANAGEMENT PROTOCOL OF
CST
 Positive CST is usually repeated in 24
hours .
 This is of historical importance .
 Not used now.
(IANDONALD 6TH ED.,GABBE 6TH ED.)
65
CONTRAINDICATIONS
• Placenta previa
• Previous CS
• Multiple gestation
• Polyhydroamnios
• History of preterm
• Incompetent cervix
66
Nipple stimulation test
• Alternative method of performing CST
• ACOG Recommends stimulation through
light clothing for two minutes at a
time with rest interval of five
minutes.
• Adequate uterine contractions
obtained with in four minutes of
stimulation.
• (IANDONALD 6TH ED.)
67
DOPPLER VELOCIMETRY
• Noninvasive technique to assess blood
flow by characterizing downstream
impedance
• Three fetal AND one maternal vascular
circuits :-
Umbilical artery,
• Middle cerebral artery
• Ductus venosus
• Uterine artery
68
INDICATIONS
• IUGR
• PIH
• GDM
• RH ISOIMMUNISATION
• INTRAHEPATIC CHOLISTASIS OF
PREGNANCY
69
UTERINE ARTERY
• INDICATIONS
(1) history of Preeclampsia
• (2) previous child with IUGR
• (3) unexplained high maternal
• serum alpha-fetoprotein level
• (4) high human chorionic gonadotropin
• level.
• (5) thrombophilias
70
The indices used to quantify
uterine artery
• systolic (S) to diastolic (D) velocity ratio
(S/D)
• pulsatility index (PI)
• resistive index (RI)
• early diastolic notching.
• Abnormalities in these indices are
defined as PI or RI above a chosen value
and/or percentile
• the presence of unilateral or bilateral
diastolic notches
71
How to calculate indices
• S/D ratio
systolic peak velocity/diastolic peak velocity
• Resistance index (RI)
systolic- end diastolic peak velocity/systolic peak
velocity
Pulsatility index (PI)
systolic-end diastolic peak velocity/time averaged
maximum −velocity
72
Facts sheet
• Uterine Doppler screening is commonly performed
around 20 weeks.
• increased uterine artery impedance to flow at 20–
24 weeks follow-up at 26–28 weeks.
• Cut-off values at 23 weeks' gestation are:-
• a mean PI above 1.5–1.61.
• mean RI above 0.57–0.58.
• Bilateral notches are found in about 25–30% of
pregnancies at 12 weeks.
• 10–15% at 20 weeks .
• 5% at 24 weeks.
• (Juriy W. Wladimiroff, Sturla H. Eik-Nes)
european practice in obst.and gynaecilogy.
73
• sensitivity is up to 85% when performed between
22 and 23 weeks’ gestation.
• high risk patients given low-dose aspirin because
of bilateral uterine artery notching at 12 to 14
weeks have an 80% reduction of placental disease
• (James 4th ed.)
74
Cont.
• An early diastolic notch in the uterine arteries
at 12 to 14 weeks suggest delayed trophoblast
invasion.
• Persistence “notching” beyond 24 weeks
• confirmatory evidence.
• (James 4th ed.)
75
76
• sensitivities and specificities of uterine
artery Doppler in low-risk populations
varied from 34% to 76% and 83% to
93%, respectively.
• predictive accuracy for early onset
preeclampsia was better than for late-
onset preeclampsia.
77
• For both preeclampsia and IUGR uterine
artery Doppler more accurate in the second
than the first trimester.
• Increased PI with notching in the second
trimester best predictor of preeclampsia.
• ( Clin Perinatol 38 (2011) 1–19)
78
Placental vascular indices
• Novel tool for estimating placental volume and
vascular blood flow.
• Calculated from 3D data formed by the voxels.
• vascularization index (VI) quantifies the
• number of color-coded voxels relative to all
voxels within the volume expressed as a
percentage.
• Flow index (FI) represents the power Doppler
signal intensity from all color-coded voxels,
• ( Clin Perinatol 38 (2011) 1–19)
79
• vascularization flow index (VFI) is the product of VI
and FI.
• Reduction in these indices may be an early marker of
placental dysfunction.
•
• Study in normal and growth-restricted pregnancies
revealed that FI, which identifies the most severe
cases of placental impairment, the most reliable index
• .
• Deciduo-myometrial VI appeared to be the best
predictor of preeclampsia. superior to uterine artery PI
at 12 and 22 weeks
• ( Clin Perinatol 38 (2011) 1–19)
80
UMBLICAL ARTERY
• Duplex Doppler ultrasound is the current
standard .
• RI,PI, S/D,PSV are used.
81
82
Wave forms at
16,20,24,28,32,36 wks
83
Reverse end diastolic flow
84
FACTS SHEET
• RI had the best discriminatory
ability when compared with the S/D ratio
(P<.05), the PI (P<.001).
S/D ratio, however, remains the most popular
index.
• S/D ratio less than or equal to 3.0.
• Resistance index less than or equal
to 0.6 is considered normal after 27
completed weeks of pregnancy.
• Benefits of this technique before 28 weeks of
gestation are uncertain. 85
86
CONT.
• Diagnostic feature of umbilical artery Doppler
waveform is the end diastolic flow.
• Absent or reverse end diastolic flow ominous
finding.
• frequency of absent end diastolic flow is
approximately 2% in high-risk pregnancies .
• 0.3% in a general obstetric population.
• In pregnancies complicated with FGR, fetal
surveillance should consist of weekly umbilical
Doppler.
• ( Clin Perinatol 38 (2011) 1–19)
• . 87
CONT.
• BPP or NST should be used either as a backup
test or simultaneously with the umbilical artery
Doppler.
• Umbilical Doppler index is high or increasing
•
•
• weekly umbilical Doppler ultrasound
• +
• Twice wkly NST/ BPP
88
MANAGEMENT WITH ABSENT END
DIASTOLIC FLOW
• Guided by the gestational age.
• >34 completed weeks Delivery
• Bw 28 to 34 completed conservative
• Daily umbilical artery Doppler, NST, and
BPP (or modified BPP)+ Ductus venosus
• Reverse flow at any gestational age
beyond 28 weeks Delivery
89
MIDDLE CEREBRAL ARTERY
• Two major applications
• Monitoring of IUGR fetuses
• Evaluate peak systolic flow in fetuses
at risk for anaemia.
90
MCA in Fetal Growth
Restriction
• Hypoxia-induced cerebrovascular
dilation
• Impedance decreases
• Increases end-diastolic blood flow
91
• Contrast to fetuses with normal growth
• Resistance of the MCA is usually higher than in
the umbilical artery.
• MCA Doppler useful to monitor the third-
trimester growth restricted Fetus.
• Redistribution may occur in the presence of
normal umbilical Doppler.
• RI and PI on MCA Doppler in IUGR fetuses
MAINSTAY
92
TECHNIQUE
• Measured at internal third of the vessel
• 50 to 100 waveforms in at least 3 sets
examined.
• Highest PSV recorded.
• Impedance to flow decreases and
maximum blood velocity increases with
advancing gestation.
93
• MCA-PSV new development.
• better parameter in the prediction of
perinatal mortality than PI/RI.
• MCA PI in IUGR fetuses can normalize
in later stages.
• MCA-PSV becomes abnormal, remains
as such.
• Ratio of MCA PI to Umbilical PI >1.5
in normal fetal circulatory condition.
94
u
95
96
MCA DOPPLER IN FETAL
ANEMIA
• RH isoimmunization
• Parvovirusinfection
• fetomaternal haemorrhage
97
• Anemic fetus increased cardiac output
• Associated with lower blood viscosity.
• So increased blood velocities
• Peak velocity in the fetal MCA
• value of greater than 1.5(MoMs) for the
corresponding GA
98
99
• MCA-PSV for the prediction of severe,
moderate, and mild anemia at a
sensitivity of 100% showed false-
positive rates of 6%, 37%, and 70%,
respectively
• Measurements can be obtained reliably
as early as 18 weeks’ gestation.
• Repeated every 1 to 2 weeks depending
on the trend.
• Values after 35wks higher rate of
false-positive results
• (GABBE 5TH ED.)
100
Ductus Venosus
• Connects the intra-abdominal portion of
the umbilical vein with the inferior vena
cava at its inlet to the right atrium.
• Shunt plays a critical role in the
delivery of well-oxygenated blood to the
left side of fetal heart.
• Sample siteInlet, where the highest
velocities are recorded
• waveform of the ductus venosus
triphasic.
Clin Perinatol 38 (2011) 103–112
101
Ductus venosus waveforms
102
• Blood flow in the ductus venosus is usually
forward in physiological conditions.
• In the first trimester (11–14 weeks), a
negative a-wave may be recorded in about 3%
of normal fetuses.
• Absolute blood flow velocities increase,
whereas the pulsatility decreases with
advancing gestation.
• This reflecs decreasing cardiac afterload and
maturation of diastolic ventricular function.
• Clin Perinatol 38 (2011) 103–112 103
104
• IUGR <32 progressive increase in ductus venosus
pulsatility paralleled by decrease of short time
variation of the fetal heart rate pattern.
• Parameters normal in late-onset growth restriction.
• Primary value in early-onset FGR.
• Perinatal mortality increases to 38.8% when venous
Doppler indices become abnormal.
• Clin Perinatol 38 (2011) 103–112
105
Management goals & protocol
• Prevention of stillbirth
• Delivery based on an accurate assessment of fetal
versus neonatal risks.
• Abnormal venous Doppler indices, mandate higher
testing frequency, up to daily testing.
• Reversal of DV a wave increases the risk for an
abnormal biophysical profile score within 1 to 8
days.
• Reversal of DV a wave only becomes an independent
risk factor for neonatal morbidity and mortality
after 27 weeks’ gestation.
106
Tests for fetal lungs maturity
• 1. L/S ratio(>2)
• 2.Shake or bubble test
• 3.foam stability index
• 4.phosphatidyl glycerol
• 5.amniotic fluid optical density.
• 6.lamellar body count (>30000/micl
• 7.amniotic fluid turbidity test
• 8. Nile blue sulphatase test
107
COCHRANE REVIEW
• ? Antenatal cardiotocography for fetal
assessment (Grivell 2010)
• No clear evidence that antenatal CTG improves
perinatal outcome.
• ? Biophysical profile for fetal assessment in
high-risk pregnancies (Lalor 2008)Not enough
evidence to support use of biophysical profile for
assessing fetal wellbeing in high-risk pregnancies
108
• Fetal and umbilical Doppler
ultrasound in high-risk pregnancies
(Alfirevic 2010)Doppler ultrasound in
high-risk pregnancies reduced the risk
of perinatal deaths and resulted in less
obstetric interventions. The evidence
was not of high quality, therefore
results should be interpreted with some
caution
109
CARRY HOME MESSAGE
• Antenatal fetal
assessment should be done
with caution to decide
time of delivery otherwise
can lead to unwarranted
interventions .
110
Thankyou
111

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assement of fetal well being

  • 1. Antepartum assessment of fetal well being Presented by Dr. Pankaj sharma igmc shimla dr.pankajigmc789618@gmail.com 1
  • 2. HISTORY • Fetal heart sounds first detected by Marsac in the 1600A.D. • Can be used to determine fetal well being was first proposed by Killian in the 1600’s. • Mayor and Kergaradec described the method of auscultating fetal heart sounds by placing the ear next to the maternal abdomen. . • In 1893, Von Winkel established criteria for fetal distress that remained unchanged until the advent of electronic fetal monitoring 2
  • 3. INTRODUCTION • ANTENATAL FETAL SURVEILLANCE IS ASSESSMENT OF FETAL WELL BEING IN ANTEPARTUM PERIOD TO ENSURE DELIVERY OF HEALTHY NEONATE. Two main objectives are:-  Early detection of fetuses at risk to prevent perinatal mortality and morbidity.  Find out normal fetuses and avoid unwarranted interventions. 3
  • 4. ANTEPARTUM FETAL ASSESSMENT • METHODS:- • 1a CLINICAL ASSESSMENT • Weight gain • Fundal height • Abdominal girth • Auscultation of fetal heart • 1b fetal movement count by mother • 2.ultrasound for fetal parameters • 3.biochemical tests • 4.NST • 5.VAST • 6.CST 4
  • 5. • 7.Nipple stimulation test • 8.biophysical profile • 9.doppler • 10.fetal lung maturation test • 11.placental grading 5
  • 6. INDICATIONS • MATERNAL • FETAL • PREGNANCY RELATED • MATERNAL • Hypertension • Diabetes • Heart disease • Chronic renal disease • Sever anemia • APLA • Acute illnesses 6
  • 7. Fetal • Fetal growth restriction • Rh isoimmunisation • Fetal cardiac arrythmias • Fetal infections 7
  • 8. PREGNANCY RELATED • Multiple pregnancy • Gestational hypertension • Preeclampsia • Decreased fetal movement • Abnormal placentation • Placental abruption • Amniotic fluid disorders • PROM • GDM • Previous unexplained still birth • ICP • Post term pregnancy 8
  • 9. WHEN TO START? • Depends up on factors like:- • Past history of adverse outcome • Severity of maternal and fetal conditions • Generally Monitoring is recommended when estimated fetal maturity is sufficient to expect a reasonable chance of survival should intervention be necessary. 9
  • 10. CLINICAL ASSESSMENT • WEIGHT GAIN 10 Recommended Ranges of Weight Gain During Singleton Gestations Stratified by Pre pregnancy Body Mass Index Category BMI Wt. in kgs kg Low 19.8 12.5–18 Normal 19.8–26 11.5–16 High 26–29 7–11.5 Obese 29 7 (Williams 23rd ed.)
  • 11. Symphysio-fundal height • Measured from superior border of pubis symphysis to fundus • From 24th wks of gestation corresponds to period of gestation . • Difference of 3-4 cms acceptable • below 10th percentile or difference of >4cms suggests IUGR • positive predictive value of60% negative predictive value of 76.8% 11
  • 12. Abdominal girth • Measured at lower border of umbilicus. • Increases by 2.5cm per week after 30wks. • 95-100cms at term. • Static or falling values alarming sign. 12
  • 13. Fetal movement count • Cardiff” count 10” technique • Daily fetal movement count • Perception of three movement in 30 minutes. • Sadovsky’s “movement alarm signal”fewer than three movements an hour for 2 consecutive days. GABBE 6TH ED. 13
  • 14. Fetal movement count • Fetus spends 10% of its time making gross fetal body movements • 30 such movements made each hour. • Periods of active fetal body movement last about 40 minutes • Quiet periods last about 20 minutes. • Longest period without fetal movements about 75 minutes. • Mother appreciate 70% to 80% of gross fetal movements. • (GABBE 6TH ED.) 14
  • 15. • Fetal movement peak between 9:00 PM and 1:00 AM. • Time when maternal glucose levels are falling. • Holden and coworkers hypoglycemia associated with increased fetal movement. Fetal activity does not increase after meals or after maternal glucose administration. (GABBE 6TH ED.) 15
  • 16. • Cochrane review of four trials in 2007 concluded that there is insufficient evidence to recommend routine fetal movement counting to prevent fetal death. • positive predictive value of the maternal perception of reduced FM for fetal compromise 2% to 7% • Despite these results, there may be some advantages to this type of fetal assessment. 16
  • 17. Factors affecting maternal perception of fetal movement • Fetal and placental factors :- • Placental location • The length and type of fetal movements • Amniotic fluid volume (AFV) • Maternal factors :- • Parity, obesity. • Psychological factors anxiety. 17
  • 18. • Froen and associates, found in a cohort of 1200 women instructed to start their fetal movement count at the first convenient time of the day that the mean time to count to 10 was less than 10 minutes. (GABBE 6TH ED.) 18
  • 19. ULTRASOUND FOR FETAL PARAMETERS • HIGH RESOLUTION UTRASOUND REVOLUTIONIZED PRENATAL DIAGNOSIS. • CAN BE:- • BASIC • TARGETED • BASIC:-(in early pregnancy) • Done at 10-14wks and includes :- • No. of fetuses • Fetal life • Placental localization • Internal os diameter • Cervical length 19
  • 20. • Gestational age • maternal pelvic masses • Any gross anomaly like anencephaly,limb reduction defects. • Nuchal translucency(80% fetuses with 5% false positive rates) • Only in high risk patients 20
  • 21. • CRL smaller than gestational age chromalsomal anomalies Absencence of nasal bone at 10-12wks Down syndrome NB+NT detection rate of 92% & false positive rate of 3.5% Dutta 7th ed. 21
  • 22. 2nd &3rd triemester • Serial measurements of BPD,AC,HC,FL. • HC/AC ratio exceeds 1 before 32wks. • 1 bw 32to 34wks. After 34wk falls below 1. • In symmetric IUGR remains normal. • Ratio can identify 85% IUGR fetuses. • FL/AC remains 22 at all gestational ages from 21wks to term. >23.5 suggest IUGR. • AC remains single best parameter to detect IUGR with positive predictive value of 50%. • Trans cerebellar diameter in mm corresponds to POG from 11wks – 32wks . • (James 4th ed.) 22
  • 23. AMNIOTIC FLUID VOLUME • Single deepest pocket >2cm normal • Or • Amniotic fluid index 5-25cm. (five quadrant technique.) 23
  • 24. Targetted ultrasound • Done in high risk patients • In developed countries offered to all patients • Transverse section for fetal head • Shape and internal structures. BPD,HC Measured to detect hydrocephalus,anencephaly • Transverse and longitudinal views of abdomen to rule out anomaliesofstomach,kidneys,bladder,ventral wall. • Transverse section of fetal thorax to four chambered view of heart. 24
  • 25. Four chambered view of heart 25
  • 26. • Identify three long bones in each limb and any achondroplasia is iooked for. • Saggittal ,coronal and transverse views taken to rule out spinabifida. cephalic index Biparietal diameter/occipitofrontal diameter • Age-independent • Identify dolichocephaly and brachycephaly. 26
  • 27. Fetal ECHO • Indications Fetal risk factors • Suspected cardiac anomaly on level I scan • Nuchal thickening/lucency • Diaphragmatic hernia • Duodenal atresia • Tracheoesophageal fistula • Cystic hygroma • Chromosomal abnormalities • Twin–twin transfusion • Acardiac twin • Vein of Galen aneurysm (Nadas' Pediatric Cardiology, 2nd ed.) 27
  • 28. • Maternal risk factors • • Congenital heart disease • Exposure to teratogen • Diabetes • Maternal infections Familial risk factors • Trisomy 21 (Down) • Marfan • Noonan • Tuberous sclerosis • Velocardiofacial/DiGeorge (Nadas' Pediatric Cardiology, 2nd ed). 28
  • 29. • Historically optimal timing between 18 and 22 weeks’ gestation. • moving into an era of early risk assessment . • fetal echocardiography late first and early second trimesters • A limited number of reports describe the utility of transvaginal imaging between 10 and 13 weeks. (Ultrasound Clin 6 (2011) 47–56) 29
  • 30. Non stress test • Freeman first described the NST in 1975. • Physiologic premise of the NST is that:- Nonhypoxic fetus stimulus • • • accelerate its heart rate 30
  • 31. Method • Patient is placed in a lateral tilt position • FHR and uterine activity are monitored with an external transducer • FHR is monitored for 20 minutes. • For 40 minutes in some cases to compensates for sleep cycles then called EXTENDED NST. • In some cases when the fetus is not reactive, acoustic stimulation by artificial larynx a sound stimulus for 1 to 2 seconds. 31
  • 32. INTERPRETATION • Reactive NST presence of two accelerations of 15bpm over base line for 15sec in a 20- minute time period with or without fetal movements. • Nonreactive NST absence of two accelerations in a 40-minute period with or without acoustic stimulation over a 40-minute period. 32
  • 33. WHEN TO START ? • NST is not routinely started until 32- weeks gestation. • Up to 50% of NSTs reactive from 24- to 28-weeks gestation. • 85% from 28 to 32 weeks of gestation • In up to 50% of NSTs variable decelerations may be observed. • If last for <30 seconds and <2 during a 20-minute period NO fetal compromise 33
  • 34. PREDICTIVE VALUE • With a reactive NST, the chance for fetal death within 1 week is 1.9 per 1,000, giving a negative predictive value of 99.8% after correction for lethal anomalies. • Best senstivity and positive predictive value for IUGR and Hypertensive disorders -70% • Reactive NST is reassuring. • Nonreactive NST is nonspecific and requires further evaluation. (Pediatr Clin N Am 56 (2009) 489– 504) 34
  • 35. • The false-positive rate is considerably higher, ranging from 50% to more than 90% in various studies. • In high-risk pregnancies, the false- negative rate associated with a weekly NST may be unacceptably high. • In these cases, increasing frequency of the NST to twice weekly may be considered. • (GABBE 6TH ED.) 35
  • 36. VIBROACOUSTIC STIMULATION TEST • Used as an adjunct to NST • If NST non reactive even after 40min then:- • Continue CTG monitoring till 90min OR Perform BPP OR VAST 36
  • 37. • Auditory brainstem response functional at 26 to 28 weeks’ gestation. • VAST increase the incidence of reactive NSTs after 26 weeks’ gestation . • Reduce the testing time. • artificial larynx that generates sound 82 Db -100db with a frequency of 80 Hz. 37
  • 38. • A stimulus for 3 seconds or less is applied near the fetal head. • If the NST remains nonreactive • Stimulus is repeated at 1-minute intervals up to three times. • (GABBE 6TH ED.) 38
  • 39. • VAST have shown a decreased incidence of nonreactive NSTs from 13% to 14% down to 6% to 9%. • SAFETY • Arulkumaran and associate found:- “ intrauterine sound levels from VAST were not hazardous to the fetal ear.” • no long-term evidence of hearing loss in children followed in the neonatal period and up to 4 years of age. • (GABBE 6TH ED.) 39
  • 40. MANAGEMENT PROTOCOL OF NST NST for 20 min Reactive Repeate after 1wk Or earlier if situation demands • If non reactive Extend to 40min • Non reactive VAST Non reactive BPP 40
  • 41. BIOPHYSICAL PROFILE • Thorough evaluation of fetal well-being . • Potential to significantly reduce the false-positive rate of the NST/CST. • The BPP was initially described by Manning and colleagues in 1980. • Vintzileos and colleagues subsequently proposed an alternative BPP scoring system. • Rationale:-Fetal biophysical activities controlled by centers in the fetal brain sensitive to varying degrees of hypoxia. 41
  • 42. BPP SCORING( MANNING) 1. Movements Three or more gross body movements SCORE • in a 30-minute period. • Simultaneous trunk and limb 2 • movements count as a single • Movement • Fewer than 3 gross body movements 0 • in a 30-minute period 42
  • 43. CONT. SCORE • 2. TONE At least one movement of a limb from • a position of flexion to one of extension, 2 • with a rapid return to flexion. • Fetal limb in extension with no return 0 • to flexion with movement • 3.Breathing At least 30 seconds of sustained • FBMs observed over a 30-minute period 2 • Fewer than 30 seconds of sustained • FBMs observed over a 30-minute 0 43
  • 44. Cont. • SCORE • 4.AFPAt least a single amniotic fluid pocket • measuring 2 cm in 2 perpendicular planes 2 • No amniotic fluid pocket that 0 • measures at least 2 cm • 2 perpendicular planes • 5. NST reactive 2 • NST non reactive 0 44
  • 45. 45
  • 46. Vintzileos Scoring • Nonstress test • Score 2 (NST 2): 5 or more FHR accelerations of at least 15 beats per minutes (bpm) in amplitude and at least 15-second duration associated with FMs in a 20- minute period. • Score 1 (NST 1): 2 to 4 accelerations of at least 15 bpm in amplitude and at least 15-second • duration associated with FMs in a 20-minute period. • Score 0 (NST 0): 1 or less acceleration in a 20-minute period. 46
  • 47. Fetal movements • Score 2 (FM 2): at least 3 gross (trunk and limbs) episodes of FMs within 30 minutes. • Score 1 (FM 1): 1 or 2 FMs within 30 minutes. • Score 0 (FM 0): absence of FMs within 30 minutes. 47
  • 48. Fetal breathing movements • Score 2 (FBM 2): at least 1 episode of fetal breathing of at least 60-second duration within a 30-minute observation period. • Score 1 (FBM 1): at least 1 episode of fetal breathing lasting 30 to 60 seconds within 30 • minutes. • Score 0 (FBM 0): absence of fetal breathing or breathing lasting less than 30 seconds within 30 minutes. 48
  • 49. Fetal tone • Score 2 (FT 2): at least 1 episode of extension of extremities with return to position of flexion and also 1 episode of extension of spine with return to position of flexion. • Score 1 (FT 1): at least 1 episode of extension of extremities with return to position of flexion or 1 episode of extension of spine with return to flexion. • Score 0 (FT 0): extremities in extension. FMs not followed by return to flexion. 49
  • 50. Amniotic fluid volume • Score 2 (AF 2): fluid evident throughout the uterine cavity. A pocket that measures greater than 2 cm in vertical diameter. • Score 1 (AF 1): a pocket that measures less than 2 cm but more than in vertical diameter. • Score 0 (AF 0): crowding of fetal small parts. Largest pocket less than 1 cm in vertical diameter. 50
  • 51. Placental grading • Score 2 (PL 2): placental grading 0, 1, or 2. • Score 1 (PL 1): placenta posterior difficult to evaluate. • Score 0 (PL 0): placental grading 3. Maximal score, 12; minimal score, 0. • (Clin Perinatol 38 (2011) 47–64) 51
  • 52. Technique • Performance of an NST. • For gestations less than 32 weeks, the qualifying criteria for accelerations are greater than 10 bpm, lasting at least 10 seconds. • Real-time ultrasound • The time required related to fetal state, with an average of only 5 minutes if the fetus is in a 2F state but over 25 minutes if it is in a 1F state. 52
  • 53. MANAGEMENT PROTOCOL OF BPP • 10 Normal; low risk for chronic asphyxia Repeat testing at weekly to twice-weekly intervals (IN HIGH RISK CASES) • 8 Normal; low risk for chronic asphyxia Repeat testing at weekly to twice-weekly intervals If oligohydroamnios deliver. • 6 Suspect chronic asphyxia If ≥36-37 wk gestation or <36 wk with positive testing for fetal pulmonary maturity, consider delivery. Otherwise repeat with in 24hrs • if <36 wk and/or fetal pulmonary maturity testing negative, repeat biophysical profile in 4 to 6 hr. • deliver if oligohydramnios is present 53
  • 54. • 4 Suspect chronic asphyxia If ≥36 wk gestation, deliver. • if <32 wk gestation, repeat with in 24hrs. If repeat score <6 deliver if >6 observe. • 0-2 Strongly suspect chronic asphyxia Extend testing time to 120 min. • if persistent score ≤4, deliver, regardless of gestational age • 54
  • 55. PREDICTIVE VALUE OF BPP • To summarize the results of multiple studies, the false-negative rate of a normal BPP is less than 0.1%, or fewer than 1 fetal death per 1000 within 1 week of a normal BPP 55
  • 56. 56Clin Perinatol 38 (2011) 47–64)
  • 57. • NST and FBM Has highest senstivity • Fetal tone has highest specificity 57
  • 58. MODIFIED BPP • Attempt to simplify and reduce the time. • Focusing on the components of the BPP most predictive of perinatal outcome. • Two parameters:- • 1. NST indicator of present fetal condition. • 2. AFI /AFP a marker of long-term status. 58
  • 59. Predictive value • Miller have demonstrated comparable results of the mBPP to the full BPP. • False-negative rate (or rate of fetal death within 1 week of a normal mBPP) of 0.8 per 1000. • Modified BPP has a false-positive rate comparable to the NST. • But higher than the CST and full BPP. • AFI or DVP under investigation. (GABBE 6TH ED.) 59
  • 60. • Chauhan and colleagues found that the AFI led to more diagnoses of oligohydramnios and a higher rate of intervention without improving outcome. 60
  • 61. Contraction Stress Test CST/OCT first biophysical technique widely applied for antepartum fetal surveillance. Principle uterine contractions Reduction in blood flow to the intervillous space. Inadequate placental respiratory reserve Recurrent late decelerations in response to hypoxia. 61
  • 62. TECHNIQUE  Patient is placed in the semi-Fowler’s position at a 30- to 45-degree angle with a slight left tilt .  Fetal heart rate and uterine contraction baseline is determined.  Blood pressure is recorded every 5 to 10 minutes to detect maternal hypotension.  oxytocin started @.5-1 miu /min.  An adequate CST requires uterine contractions of moderate intensity lasting about 40 to 45 seconds with a frequency of three in 10 minutes. 62
  • 63. INTERPRETATION  Negative: No late or significant variable decelerations  Positive: Late decelerations with at least 50% of contractions  Suspicious: Intermittent late or variable decelerations  Hyperstimulation: Decelerations with contractions longer than 90 seconds’ duration or 2-minute frequency  Unsatisfactory: Fewer than three contractions per 10 minutes or an uninterpretable tracing 63
  • 64. PREDICTIVE VALUE OF CST • A negative CST good fetal outcome. • incidence of perinatal death within 1 week of a negative CST (i.e., the false-negative rate) to be less than 1 per 1000. 64
  • 65. MANAGEMENT PROTOCOL OF CST  Positive CST is usually repeated in 24 hours .  This is of historical importance .  Not used now. (IANDONALD 6TH ED.,GABBE 6TH ED.) 65
  • 66. CONTRAINDICATIONS • Placenta previa • Previous CS • Multiple gestation • Polyhydroamnios • History of preterm • Incompetent cervix 66
  • 67. Nipple stimulation test • Alternative method of performing CST • ACOG Recommends stimulation through light clothing for two minutes at a time with rest interval of five minutes. • Adequate uterine contractions obtained with in four minutes of stimulation. • (IANDONALD 6TH ED.) 67
  • 68. DOPPLER VELOCIMETRY • Noninvasive technique to assess blood flow by characterizing downstream impedance • Three fetal AND one maternal vascular circuits :- Umbilical artery, • Middle cerebral artery • Ductus venosus • Uterine artery 68
  • 69. INDICATIONS • IUGR • PIH • GDM • RH ISOIMMUNISATION • INTRAHEPATIC CHOLISTASIS OF PREGNANCY 69
  • 70. UTERINE ARTERY • INDICATIONS (1) history of Preeclampsia • (2) previous child with IUGR • (3) unexplained high maternal • serum alpha-fetoprotein level • (4) high human chorionic gonadotropin • level. • (5) thrombophilias 70
  • 71. The indices used to quantify uterine artery • systolic (S) to diastolic (D) velocity ratio (S/D) • pulsatility index (PI) • resistive index (RI) • early diastolic notching. • Abnormalities in these indices are defined as PI or RI above a chosen value and/or percentile • the presence of unilateral or bilateral diastolic notches 71
  • 72. How to calculate indices • S/D ratio systolic peak velocity/diastolic peak velocity • Resistance index (RI) systolic- end diastolic peak velocity/systolic peak velocity Pulsatility index (PI) systolic-end diastolic peak velocity/time averaged maximum −velocity 72
  • 73. Facts sheet • Uterine Doppler screening is commonly performed around 20 weeks. • increased uterine artery impedance to flow at 20– 24 weeks follow-up at 26–28 weeks. • Cut-off values at 23 weeks' gestation are:- • a mean PI above 1.5–1.61. • mean RI above 0.57–0.58. • Bilateral notches are found in about 25–30% of pregnancies at 12 weeks. • 10–15% at 20 weeks . • 5% at 24 weeks. • (Juriy W. Wladimiroff, Sturla H. Eik-Nes) european practice in obst.and gynaecilogy. 73
  • 74. • sensitivity is up to 85% when performed between 22 and 23 weeks’ gestation. • high risk patients given low-dose aspirin because of bilateral uterine artery notching at 12 to 14 weeks have an 80% reduction of placental disease • (James 4th ed.) 74
  • 75. Cont. • An early diastolic notch in the uterine arteries at 12 to 14 weeks suggest delayed trophoblast invasion. • Persistence “notching” beyond 24 weeks • confirmatory evidence. • (James 4th ed.) 75
  • 76. 76
  • 77. • sensitivities and specificities of uterine artery Doppler in low-risk populations varied from 34% to 76% and 83% to 93%, respectively. • predictive accuracy for early onset preeclampsia was better than for late- onset preeclampsia. 77
  • 78. • For both preeclampsia and IUGR uterine artery Doppler more accurate in the second than the first trimester. • Increased PI with notching in the second trimester best predictor of preeclampsia. • ( Clin Perinatol 38 (2011) 1–19) 78
  • 79. Placental vascular indices • Novel tool for estimating placental volume and vascular blood flow. • Calculated from 3D data formed by the voxels. • vascularization index (VI) quantifies the • number of color-coded voxels relative to all voxels within the volume expressed as a percentage. • Flow index (FI) represents the power Doppler signal intensity from all color-coded voxels, • ( Clin Perinatol 38 (2011) 1–19) 79
  • 80. • vascularization flow index (VFI) is the product of VI and FI. • Reduction in these indices may be an early marker of placental dysfunction. • • Study in normal and growth-restricted pregnancies revealed that FI, which identifies the most severe cases of placental impairment, the most reliable index • . • Deciduo-myometrial VI appeared to be the best predictor of preeclampsia. superior to uterine artery PI at 12 and 22 weeks • ( Clin Perinatol 38 (2011) 1–19) 80
  • 81. UMBLICAL ARTERY • Duplex Doppler ultrasound is the current standard . • RI,PI, S/D,PSV are used. 81
  • 82. 82
  • 85. FACTS SHEET • RI had the best discriminatory ability when compared with the S/D ratio (P<.05), the PI (P<.001). S/D ratio, however, remains the most popular index. • S/D ratio less than or equal to 3.0. • Resistance index less than or equal to 0.6 is considered normal after 27 completed weeks of pregnancy. • Benefits of this technique before 28 weeks of gestation are uncertain. 85
  • 86. 86
  • 87. CONT. • Diagnostic feature of umbilical artery Doppler waveform is the end diastolic flow. • Absent or reverse end diastolic flow ominous finding. • frequency of absent end diastolic flow is approximately 2% in high-risk pregnancies . • 0.3% in a general obstetric population. • In pregnancies complicated with FGR, fetal surveillance should consist of weekly umbilical Doppler. • ( Clin Perinatol 38 (2011) 1–19) • . 87
  • 88. CONT. • BPP or NST should be used either as a backup test or simultaneously with the umbilical artery Doppler. • Umbilical Doppler index is high or increasing • • • weekly umbilical Doppler ultrasound • + • Twice wkly NST/ BPP 88
  • 89. MANAGEMENT WITH ABSENT END DIASTOLIC FLOW • Guided by the gestational age. • >34 completed weeks Delivery • Bw 28 to 34 completed conservative • Daily umbilical artery Doppler, NST, and BPP (or modified BPP)+ Ductus venosus • Reverse flow at any gestational age beyond 28 weeks Delivery 89
  • 90. MIDDLE CEREBRAL ARTERY • Two major applications • Monitoring of IUGR fetuses • Evaluate peak systolic flow in fetuses at risk for anaemia. 90
  • 91. MCA in Fetal Growth Restriction • Hypoxia-induced cerebrovascular dilation • Impedance decreases • Increases end-diastolic blood flow 91
  • 92. • Contrast to fetuses with normal growth • Resistance of the MCA is usually higher than in the umbilical artery. • MCA Doppler useful to monitor the third- trimester growth restricted Fetus. • Redistribution may occur in the presence of normal umbilical Doppler. • RI and PI on MCA Doppler in IUGR fetuses MAINSTAY 92
  • 93. TECHNIQUE • Measured at internal third of the vessel • 50 to 100 waveforms in at least 3 sets examined. • Highest PSV recorded. • Impedance to flow decreases and maximum blood velocity increases with advancing gestation. 93
  • 94. • MCA-PSV new development. • better parameter in the prediction of perinatal mortality than PI/RI. • MCA PI in IUGR fetuses can normalize in later stages. • MCA-PSV becomes abnormal, remains as such. • Ratio of MCA PI to Umbilical PI >1.5 in normal fetal circulatory condition. 94
  • 95. u 95
  • 96. 96
  • 97. MCA DOPPLER IN FETAL ANEMIA • RH isoimmunization • Parvovirusinfection • fetomaternal haemorrhage 97
  • 98. • Anemic fetus increased cardiac output • Associated with lower blood viscosity. • So increased blood velocities • Peak velocity in the fetal MCA • value of greater than 1.5(MoMs) for the corresponding GA 98
  • 99. 99
  • 100. • MCA-PSV for the prediction of severe, moderate, and mild anemia at a sensitivity of 100% showed false- positive rates of 6%, 37%, and 70%, respectively • Measurements can be obtained reliably as early as 18 weeks’ gestation. • Repeated every 1 to 2 weeks depending on the trend. • Values after 35wks higher rate of false-positive results • (GABBE 5TH ED.) 100
  • 101. Ductus Venosus • Connects the intra-abdominal portion of the umbilical vein with the inferior vena cava at its inlet to the right atrium. • Shunt plays a critical role in the delivery of well-oxygenated blood to the left side of fetal heart. • Sample siteInlet, where the highest velocities are recorded • waveform of the ductus venosus triphasic. Clin Perinatol 38 (2011) 103–112 101
  • 103. • Blood flow in the ductus venosus is usually forward in physiological conditions. • In the first trimester (11–14 weeks), a negative a-wave may be recorded in about 3% of normal fetuses. • Absolute blood flow velocities increase, whereas the pulsatility decreases with advancing gestation. • This reflecs decreasing cardiac afterload and maturation of diastolic ventricular function. • Clin Perinatol 38 (2011) 103–112 103
  • 104. 104
  • 105. • IUGR <32 progressive increase in ductus venosus pulsatility paralleled by decrease of short time variation of the fetal heart rate pattern. • Parameters normal in late-onset growth restriction. • Primary value in early-onset FGR. • Perinatal mortality increases to 38.8% when venous Doppler indices become abnormal. • Clin Perinatol 38 (2011) 103–112 105
  • 106. Management goals & protocol • Prevention of stillbirth • Delivery based on an accurate assessment of fetal versus neonatal risks. • Abnormal venous Doppler indices, mandate higher testing frequency, up to daily testing. • Reversal of DV a wave increases the risk for an abnormal biophysical profile score within 1 to 8 days. • Reversal of DV a wave only becomes an independent risk factor for neonatal morbidity and mortality after 27 weeks’ gestation. 106
  • 107. Tests for fetal lungs maturity • 1. L/S ratio(>2) • 2.Shake or bubble test • 3.foam stability index • 4.phosphatidyl glycerol • 5.amniotic fluid optical density. • 6.lamellar body count (>30000/micl • 7.amniotic fluid turbidity test • 8. Nile blue sulphatase test 107
  • 108. COCHRANE REVIEW • ? Antenatal cardiotocography for fetal assessment (Grivell 2010) • No clear evidence that antenatal CTG improves perinatal outcome. • ? Biophysical profile for fetal assessment in high-risk pregnancies (Lalor 2008)Not enough evidence to support use of biophysical profile for assessing fetal wellbeing in high-risk pregnancies 108
  • 109. • Fetal and umbilical Doppler ultrasound in high-risk pregnancies (Alfirevic 2010)Doppler ultrasound in high-risk pregnancies reduced the risk of perinatal deaths and resulted in less obstetric interventions. The evidence was not of high quality, therefore results should be interpreted with some caution 109
  • 110. CARRY HOME MESSAGE • Antenatal fetal assessment should be done with caution to decide time of delivery otherwise can lead to unwarranted interventions . 110