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PRINCIPLES OF FETAL MONITORING<br />MohdHanafiRamlee<br />
I’M SORRY, I CAN’T INTERPRET SOME OF THE PICTURE HERE!!!BUT I’LL TRY MY BEST!!!<br />
AIMS OF FETAL MONITORING<br />Assessment of fetal well-being especially in high-risk mother<br />Assessments of fetal grow...
Antenatal monitoring<br />Labour monitoring<br />
WEIGHT GAIN<br /><ul><li>Cheap and simple method using weighing machine
Mother should gain 0.5 kg/week during 2nd and early 3rd trimester  then, the rate of weight gain is plateaus off
↓: possibilities of IUGR, persistent nausea and vomiting or forced dieting
↑: PIH, renal disease and polyhydramnios.</li></li></ul><li>SYMPHYSIOFUNDAL HEIGHT<br /><ul><li>At least 2 times weekly
The centimeters should roughly correspond to the period of gestation
↑: polyhydramnios
↓: oligohydramnios</li></li></ul><li>
FETAL KICK CHART<br />Commonest methods – Cardiff ‘count to ten’<br />Start count at 9am every morning<br />Record the tim...
A FAVOURABLE FETAL MOVEMENT CHART<br />Day<br />Patient’s Name<br />Time (am/pm))<br />
AN UNFAVOURABLE FETAL MOVEMENT CHART<br />Day<br />Patient’s Name<br />Time (am/pm))<br />
DIAGNOSTIC ULTRASOUND SCAN<br />- 2 dimensional map of content of uterus.<br />- Image constantly updated in real time and...
transvaginal -TRANDUCER - abdominal<br />
Age Assessment<br />Early Problems<br />Measurement<br />Amniotic Fluid Volume<br />Symmetry<br />Umbilical Cord Abnormali...
EARLY PREGNANCY PROBLEMS<br />- transvaginal ultrasound role in diagnosis of disorder in early pregnancy.<br />E.g. miscar...
FETAL MEASUREMENTS<br />
FETAL MEASUREMENT<br />Common = relatively ‘spared’ in growth restriction<br />Sensitive = organ that are sensitive to cha...
CROWN-RUMP LENGTH<br />
CROWN-RUMP LENGTH<br />Geatational sac<br />Yolk sac<br />Fetal pole<br />
BPD, HC LENGTH<br />Biparietal diameter<br />Head circumference<br />
BPD, HC LENGTH<br />
FEMUR LENGTH<br />Femur length<br />
FEMUR LENGTH<br />
ABDOMINAL CIRCUMFERENCE<br />Abdominal Circumference<br />
GESTATIONAL AGE ASSESSMENT<br />CRL/BPD  these measurements are plotted on the normogram<br />Predictions of gestational ...
MEASUREMENT ON FETAL GROWTH CHART<br />
Consistent growth of <br />Small fetus<br />
Slowed growth—<br />fetal compromise<br />
FETAL SYMMETRY<br />↑HC: Hydrocephalus<br />↓HC: Microcephaly<br />↓FL: constitutional short stature, achondroplasia<br />...
PLACENTA<br />Transvaginal scan: if the placenta covers the internal os major placenta praevia<br />Mid pregnancy scan  ...
OTHERS CONDITION<br />Amniotic Fluid scan: commonly base on AFI [if <2cm: Oligohydramnious, >7cm: Polyhdramnious]<br />Umb...
AIMS OF ROUTINE ULTRASOUND SCAN<br />
Magnetic Resonance Imaging: useful when i) US images are not diagnostic or ii) suboptimal because of maternal obesity<br />
MRI<br />
39<br />AMNIOTIC FLUID<br /><ul><li>Produce: Kidneys & Lungs
Remove: Fetal swallowing and blood
Functions : Prevent mechanical injury, permit    </li></ul>                      movement and lung development <br /><ul><...
DOPPLER ULTRASOUND<br /><ul><li>Measuring blood velocity in umbilical artery of fetus.
Recorded in waveform pattern :
Systolic  - blood velocity speeds up.
Diastolic - blood velocity slows down (depending 			amount resistant in arterial bed in 			placenta).</li></li></ul><li>Do...
Doppler Uterine Artery Waveforms<br />Assessment of uterine artery waveforms at 24th weeks’ gestation.<br />Benefits: Even...
Principles of Fetal Monitoring<br />49<br />Cardiotocograph (CTG)<br /><ul><li>Computerized tracing of fetal heart rate pa...
Sensitive
Reflects physiological and pathological changes</li></li></ul><li>Principles of Fetal Monitoring<br />50<br />CTG Paramete...
<110 bpm = bradycardia
>160 bpm = tachycardia</li></li></ul><li>Principles of Fetal Monitoring<br />51<br />Baseline variability :<br /><ul><li>R...
Modified by :
Fetal sleep states and activity.
Hypoxia.
Fetal infection.
Drugs e.g. opioids and hypnotics (reduce baseline variability).
Baseline variability – 8 bpm and 2-6 times in </li></ul>                                 a minute.<br />
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Foetal Monitoring

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Foetal Monitoring

  1. 1. PRINCIPLES OF FETAL MONITORING<br />MohdHanafiRamlee<br />
  2. 2. I’M SORRY, I CAN’T INTERPRET SOME OF THE PICTURE HERE!!!BUT I’LL TRY MY BEST!!!<br />
  3. 3. AIMS OF FETAL MONITORING<br />Assessment of fetal well-being especially in high-risk mother<br />Assessments of fetal growth<br />Identification of fetal abnormalities and condition in all stages of pregnancy<br />Determination of gestational period<br />To ensure a safe delivery<br />
  4. 4. Antenatal monitoring<br />Labour monitoring<br />
  5. 5.
  6. 6. WEIGHT GAIN<br /><ul><li>Cheap and simple method using weighing machine
  7. 7. Mother should gain 0.5 kg/week during 2nd and early 3rd trimester  then, the rate of weight gain is plateaus off
  8. 8. ↓: possibilities of IUGR, persistent nausea and vomiting or forced dieting
  9. 9. ↑: PIH, renal disease and polyhydramnios.</li></li></ul><li>SYMPHYSIOFUNDAL HEIGHT<br /><ul><li>At least 2 times weekly
  10. 10. The centimeters should roughly correspond to the period of gestation
  11. 11. ↑: polyhydramnios
  12. 12. ↓: oligohydramnios</li></li></ul><li>
  13. 13. FETAL KICK CHART<br />Commonest methods – Cardiff ‘count to ten’<br />Start count at 9am every morning<br />Record the time taken for baby to move 10 times <br />Normal fetal activity-little variation in time taken<br />↓ fetal activity [fetal compromise] - delay in time taken<br />Benefit: detection of fetal compromise, more easier and cheap<br />Limitation: Maternal anxiety is common, unsure of movement, is a crude guide and sometimes inconsistent<br />
  14. 14. A FAVOURABLE FETAL MOVEMENT CHART<br />Day<br />Patient’s Name<br />Time (am/pm))<br />
  15. 15. AN UNFAVOURABLE FETAL MOVEMENT CHART<br />Day<br />Patient’s Name<br />Time (am/pm))<br />
  16. 16.
  17. 17.
  18. 18. DIAGNOSTIC ULTRASOUND SCAN<br />- 2 dimensional map of content of uterus.<br />- Image constantly updated in real time and fetal cardiac and other movement can be studied.<br />- < 12 weeks usage oftransvaginaltransducer.<br />- > 12 weeks usage of abdominal transducer.<br />- Good image depend on operator skill.<br />- Disadvantages : Bio effects on cells, inducing heating.<br />
  19. 19. transvaginal -TRANDUCER - abdominal<br />
  20. 20. Age Assessment<br />Early Problems<br />Measurement<br />Amniotic Fluid Volume<br />Symmetry<br />Umbilical Cord Abnormalities<br />Growth<br />Weight<br />Invasive Procedure<br />Anatomy<br />Location<br />Morphology<br />
  21. 21. EARLY PREGNANCY PROBLEMS<br />- transvaginal ultrasound role in diagnosis of disorder in early pregnancy.<br />E.g. miscarriage <br />- fetus present, absent fetal heart<br />E.g. ectopic pregnancy<br />- absent of gestational sac within uterus<br />
  22. 22. FETAL MEASUREMENTS<br />
  23. 23. FETAL MEASUREMENT<br />Common = relatively ‘spared’ in growth restriction<br />Sensitive = organ that are sensitive to changes to any factor that cause IUGR [liver/spleen]<br />
  24. 24. CROWN-RUMP LENGTH<br />
  25. 25. CROWN-RUMP LENGTH<br />Geatational sac<br />Yolk sac<br />Fetal pole<br />
  26. 26. BPD, HC LENGTH<br />Biparietal diameter<br />Head circumference<br />
  27. 27. BPD, HC LENGTH<br />
  28. 28. FEMUR LENGTH<br />Femur length<br />
  29. 29. FEMUR LENGTH<br />
  30. 30. ABDOMINAL CIRCUMFERENCE<br />Abdominal Circumference<br />
  31. 31. GESTATIONAL AGE ASSESSMENT<br />CRL/BPD  these measurements are plotted on the normogram<br />Predictions of gestational age by ultrasound scan before 20 weeks is more accurate than predictions from last menstrual period. <br />Measurements are done at least 2 week apart<br />Measurements are plotted in centile-charts against a normogram<br />
  32. 32. MEASUREMENT ON FETAL GROWTH CHART<br />
  33. 33. Consistent growth of <br />Small fetus<br />
  34. 34. Slowed growth—<br />fetal compromise<br />
  35. 35. FETAL SYMMETRY<br />↑HC: Hydrocephalus<br />↓HC: Microcephaly<br />↓FL: constitutional short stature, achondroplasia<br />↑AC: Diabetic pregnancy,<br />↓AC: triploidy / trisomy 18<br />Asymmetry: IUGR<br />
  36. 36. PLACENTA<br />Transvaginal scan: if the placenta covers the internal os major placenta praevia<br />Mid pregnancy scan  low-lying placenta<br />3rd pregnancy scan  minor placenta praevia<br />
  37. 37. OTHERS CONDITION<br />Amniotic Fluid scan: commonly base on AFI [if <2cm: Oligohydramnious, >7cm: Polyhdramnious]<br />Umbilical Cord: scan with colourdoppler [Nuchal displacement: common event associated with fetal distress]<br />Invasive procedure: amniocentesis, chorionvillus sampling, cordocentesis, fetal bladder shunt therapy, fetoscopy and endoscope.<br />
  38. 38.
  39. 39. AIMS OF ROUTINE ULTRASOUND SCAN<br />
  40. 40. Magnetic Resonance Imaging: useful when i) US images are not diagnostic or ii) suboptimal because of maternal obesity<br />
  41. 41.
  42. 42. MRI<br />
  43. 43. 39<br />AMNIOTIC FLUID<br /><ul><li>Produce: Kidneys & Lungs
  44. 44. Remove: Fetal swallowing and blood
  45. 45. Functions : Prevent mechanical injury, permit </li></ul> movement and lung development <br /><ul><li>4 quadrant method (R/L hypocondrium R/L illiacfossa) </li></li></ul><li>AMNIOTIC FLUID INDEX<br />Liquor volume reflects the placental size, placental function and fetal metabolism<br />Sum of all the maximum vertical pool of liquor from the 4 quadrant of the uterus<br />In 3rd tri, normal AFI should be between 10 and 25cm <br />AFI -below 5cm -oligohydramnios<br /> above 25cm -polyhydramnios<br />
  46. 46.
  47. 47. DOPPLER ULTRASOUND<br /><ul><li>Measuring blood velocity in umbilical artery of fetus.
  48. 48. Recorded in waveform pattern :
  49. 49. Systolic - blood velocity speeds up.
  50. 50. Diastolic - blood velocity slows down (depending amount resistant in arterial bed in placenta).</li></li></ul><li>Doppler Umbilical Artery Waveforms<br />Measure blood velocity in umbilical artery of fetus<br />Recorded in waveform pattern showing a systolic & diastolic component<br />During normal fetal life, diastolic flow in the umbilical artery↑ gradually (placental resistance falls) withgestation<br />In placental damage/insufficiency- absent/reversed end diastolic flow which leads to fetal distress and intrauterine death.<br />
  51. 51. Doppler Uterine Artery Waveforms<br />Assessment of uterine artery waveforms at 24th weeks’ gestation.<br />Benefits: Even at absence of risk factors, severely abnormal waveforms identify 75% of pregnancies at risk of adverse neonatal outcome in early 3rd trimester.<br />Limitations: Less effective at prediction of later problems.<br />
  52. 52.
  53. 53.
  54. 54.
  55. 55.
  56. 56. Principles of Fetal Monitoring<br />49<br />Cardiotocograph (CTG)<br /><ul><li>Computerized tracing of fetal heart rate pattern
  57. 57. Sensitive
  58. 58. Reflects physiological and pathological changes</li></li></ul><li>Principles of Fetal Monitoring<br />50<br />CTG Parameters:<br />Baseline heart rate :<br /><ul><li>Normally 110 – 160bpm
  59. 59. <110 bpm = bradycardia
  60. 60. >160 bpm = tachycardia</li></li></ul><li>Principles of Fetal Monitoring<br />51<br />Baseline variability :<br /><ul><li>Reflects normal fetal autonomic nervous system.
  61. 61. Modified by :
  62. 62. Fetal sleep states and activity.
  63. 63. Hypoxia.
  64. 64. Fetal infection.
  65. 65. Drugs e.g. opioids and hypnotics (reduce baseline variability).
  66. 66. Baseline variability – 8 bpm and 2-6 times in </li></ul> a minute.<br />
  67. 67. Principles of Fetal Monitoring<br />52<br />
  68. 68. Principles of Fetal Monitoring<br />53<br />Fetal heart rate (FHR) acceleration.<br /><ul><li>Increased baseline FHR at least 15 bpm lasting at least 15 seconds.
  69. 69. Within 20 – 30 minutes CTG, 2 or more accelerations present define as reactive trace.
  70. 70. Importance – fetal hypoxia</li></li></ul><li>Principles of Fetal Monitoring<br />54<br />FHR deceleration<br /><ul><li>Transient reduction fetal heart rate of 15 bpm or > lasting more than 15 seconds.
  71. 71. Type 1 deceleration</li></ul> nadir (lowest point) of deceleration coincides with the peak of uterine contraction<br /><ul><li>Type 2 deceleration</li></ul> nadir of deceleration lags behind and persist even after the peak of uterine contraction<br /><ul><li>Variable deceleration pattern</li></ul> nadir variable in depth and timing peak of contraction<br />
  72. 72. Principles of Fetal Monitoring<br />55<br />
  73. 73. Principles of Fetal Monitoring<br />56<br />
  74. 74. Principles of Fetal Monitoring<br />57<br />
  75. 75.
  76. 76. Meconium Stained Liquor<br />Sign of fetal compromise<br />Can only be diagnose during labour, or only after the membrane have been ruptured<br />May be due to<br />Intestinal hurry<br />Spontaneous dilatation of anal<br /> sphincters<br />Manifestations of foetal hypoxia.<br />
  77. 77. OTHERS MONITORING<br />MohdHanafiRamlee<br />
  78. 78. Principles of Fetal Monitoring<br />61<br />Biochemical Screening<br />Prenatal screening test:<br /><ul><li>Fetal nuchal - measurement of fluid filled translucency space on post. surface of fetal neck.</li></ul> - increase measurement associated with fetuses with major chromosomal abnormalities and sex chromosomal abnormalities (e.g. Down syndrome).<br /><ul><li>Maternal serum screening - neural tube defect and Downsyndrome.</li></li></ul><li>Fetal Nuchal Translucency<br />Principles of Fetal Monitoring<br />62<br />
  79. 79. Principles of Fetal Monitoring<br />63<br /><ul><li>Maternal full blood indices/electrophoresis – detect thalasemia.
  80. 80. Sickledex test – sickle cell disease.
  81. 81. Maternal blood group/rhesus antibodies.
  82. 82. Maternal serum virology – CMV/toxoplasmosis/Rubella/parvovirus
  83. 83. Serology for syphilis.</li></li></ul><li>Principles of Fetal Monitoring<br />64<br />Maternal Serum Screening<br /><ul><li>15 – 20 weeks of gestation.
  84. 84. maternal serum alpha-fetoprotein (AFP) screening for neural tube defects (NTDs) and Down syndrome.
  85. 85. Increase level - fetal open NTDs.
  86. 86. Decrease level - Down syndrome. </li></ul>Screening test on Down syndrome:<br /><ul><li>maternal serum AFP.
  87. 87. human beta-chorionic gonadotropin
  88. 88. unconjugatedoestriol.
  89. 89. advanced age – risk.</li></li></ul><li>Biophysical Profile<br />
  90. 90. THANK YOU FOR YOUR ATTENTION<br />

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