Diagnositcs day 2 review


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  • Non-reactive NST does not meet the acceleration criteria Non-reactive NST’s occur more often in the preterm infant under 32 wks because they are more likely not to meet the criteria due to immature ANS Meds such as Betamethasone, alcohol, beta-blockers, muscle relaxants, and CNS depressants
  • Multiple choice
  • True or False TRUE or FALSE 8. Results of the NST can be reinforced and carry more weight when amniotic fluid volume is adequate.
  • 6. True or False Non stress tests can be facilitated by doing (VAS) Vibroaccoustic stimulation when the fetus is thought to be in a sleep mode.
  • Watch language with pt – tazer, buzzer, zapper VAS programmed for this time, push button til stops Decels common Do not use if fetus compromised or has heart issues
  • MULTIPLE CHOICE 10. The tracing above shows: a. lates and q1 min contractions b. positive CST; Non Reactive NST c. Late decelerations with hyperstimulation
  • Many studies, none to find side effects to fetus
  • Measurement of crown rump is most accurate. If LMP and crown rump measurement > 7 days, date not changed Discrepancy > 1 wk, usually due to inaccurate LMP As pregnancy progresses, measurements not as accurate for dating as genetic and other factors
  • Decreased flow to cerebral artery can indicate anemia or hypoxemia
  • Reverse flow needs immediate intervention – continous EFM AND/OR delivery
  • For ABO imcompatbilities or hyprops, can tell amt of bilirubin in amniotic fluid to see if fetus needs transfusion
  • Maternal symptoms: difficulty breathing, uterine contractions
  • Enlarged bladder with echotip needle in fetal bladder to drain bladder
  • Bladder now regular sized
  • Isoimmunization(mom antibodies attack fetal RBC), parvo virus (slows production of RBC), fetal maternal hemorrhage
  • Graph is little blurry but shows how much blood to transfuse.
  • Magnetic resonance imaging Able to separate maternal and fetal tissue, clearer image Claustrophobia, size of abd and fitting in chamber
  • Due to organ formation
  • Goal 
  • Diagnositcs day 2 review

    1. 1. Diagnostic Tests Sandy Warner RNC-OB, MSN Carrie Hallett- Voss, RNFA
    2. 2. NST - Non Stress Test <ul><li>Evaluation of FHR pattern in the absence of regular contractions to determine fetal oxygenation, neurological and cardiac function </li></ul>
    3. 3. Non Stress Test (NST) <ul><li>NST became popular as primary surveillance in mid 1970’s due to simplicity and shorter testing </li></ul><ul><li>Currently a reactive pattern is defined as 2 accelerations in 20 minutes that reach 15bpm or greater above BLFHR and lasts 15 seconds or greater </li></ul>
    4. 4. NST Definition <ul><li>Reactive NST indicates less than 1% chance of fetal death within 1 week unless there is a catastrophic event </li></ul><ul><li>Accelerations may occur either spontaneously or in association with fetal movement </li></ul><ul><li>NST done to determine the adequacy of fetal oxygenation and (CNS) autonomic function </li></ul>
    5. 5. <ul><li>Non Stress Test: </li></ul><ul><li>Benefits to patient </li></ul><ul><li>non-invasive </li></ul><ul><li>easy, inexpensive, fast </li></ul><ul><li>no known contraindications </li></ul><ul><li>good screening test </li></ul>
    6. 6. Non Stress Test (NST) <ul><li>Accelerations indicate intact neurological functioning between the fetal CNS and the fetal heart </li></ul><ul><li>Pathway may be disrupted by: </li></ul><ul><ul><li>Fetal sleep </li></ul></ul><ul><ul><li>Fetal hypoxia </li></ul></ul><ul><ul><li>Drugs (BTMS, ETOH, beta blockers, muscle relaxants, & CNS depressants) </li></ul></ul><ul><ul><li>Congenital fetal anomalies </li></ul></ul>
    7. 7. Non Stress Test (NST) <ul><li>50% of fetuses will be reactive by 26-28 weeks </li></ul><ul><li>85% of fetuses will be reactive by 28-32 weeks </li></ul><ul><li>KEYPOINT: </li></ul><ul><ul><li>Once fetus has had a reactive tracing </li></ul></ul><ul><ul><li>(15 X 15) the same reactivity is expected in further NSTs. </li></ul></ul>
    8. 8. <ul><li>Indications for NST for </li></ul><ul><li>High Risk Conditions </li></ul><ul><ul><ul><li>high risk for utero-placental insufficiency (smokers, HTN, diabetes, autoimmune disease) </li></ul></ul></ul><ul><ul><ul><li>post dates </li></ul></ul></ul><ul><ul><ul><li>motor vehicle accident (MVA) </li></ul></ul></ul><ul><ul><ul><li>previous stillbirth </li></ul></ul></ul><ul><ul><ul><li>IUGR </li></ul></ul></ul><ul><ul><ul><li>decreased fetal movement </li></ul></ul></ul><ul><ul><ul><li>isoimmunization </li></ul></ul></ul><ul><ul><ul><li>if other tests suggest fetal compromise </li></ul></ul></ul><ul><ul><ul><li>routine </li></ul></ul></ul>
    9. 9. Reactive Non Stress Test Arrows above from pushing the MARK button Indicating mother’s perception of fetal movement FM and Accelerations 15 X 15
    10. 10. <ul><li>NST Regimen </li></ul><ul><li>1986 study by Boehm showed that by increasing NST to 2 times a week, the corrected stillbirth rate dropped from 6.1 /1000 to 1.9/1000 after a reactive NST </li></ul><ul><li>Twice a week for high risk (post dates, HTN, IUGR, IDDM) </li></ul><ul><li>Once q week for other risk conditions </li></ul><ul><li>If condition no longer exists, e.g. decreased fetal movement, continued testing is not required </li></ul><ul><li>Same day evaluation for reporting of decreased fetal movement </li></ul>
    11. 11. Non Reactive NST <ul><li>Not necessarily an ominous sign, rather it does indicate the need for further testing. </li></ul><ul><li>May be followed by a BPP or a CST </li></ul><ul><li>If initially non-reactive, prolonging the period of evaluation usually allows a change in the fetal status and it becomes reactive </li></ul><ul><li>Occurs more often in the preterm fetus < 32 weeks due to immature ANS </li></ul>
    12. 12. Non Reactive NST Non Reactive NST
    13. 13. NST <ul><li>Non reactive NST with good variability probably not an indication for delivery rather, could be related to fetal adaptation to stress </li></ul>Non Stress Test (NST)
    14. 14. <ul><li>Vibroaccoustic Stimulation (VAS) </li></ul><ul><li>Artificial acoustic stimulation </li></ul><ul><li>Done after 25 wks gestation when fetus can hear </li></ul><ul><li>After 10 minutes of baseline and no accelerations, place the artificial larynx on the maternal abdomen over the fetal head </li></ul>
    15. 15. Vibroaccoustic Stimulation <ul><li>Provide 5-10 sec stimulation near fetal head, wait one minute </li></ul><ul><li>If no acceleration repeat cycle for a total of three times </li></ul><ul><li>if non-reactive after 40 minutes, proceed with further evaluation </li></ul>
    16. 16. Vibroaccoustic Stimulation <ul><li>Fetuses 28 weeks or greater respond to VAS with a consistent increase in heart rate. </li></ul><ul><li>Observed changes are greater as term is approached. </li></ul><ul><li>Can be used during version to get breech to move from midline spine to lateral spine </li></ul><ul><li>Use to startle the fetus to release cord </li></ul>
    17. 17. Contraction Stress Test <ul><li>A method of observing the response of the FHR to the stress of uterine contractions </li></ul><ul><li>A FHR response to 3 spontaneous or induced uterine contractions in 10 minutes may occur : </li></ul><ul><ul><ul><li>Spontaneously </li></ul></ul></ul><ul><ul><ul><li>Use of nipple stimulation </li></ul></ul></ul><ul><ul><ul><li>Use of Pitocin </li></ul></ul></ul><ul><li>The desired result: Negative CST (no late decelerations) </li></ul>
    18. 18. Interpretation: CST <ul><li>Negative : No late or significant variable decelerations are identified in response to 3 or more contractions lasting at least 40 seconds in a 10 minute window. </li></ul><ul><li>Positive : Late decelerations are identified with 50% or more of contractions even if the contraction frequency is less than 3 in 10 minutes. </li></ul>
    19. 19. Interpretation: CST <ul><ul><li>Suspicious : (Equivocal) inconsistent or occasional late decelerations with less than 50% of contractions. Repeat in 24 hrs. </li></ul></ul><ul><ul><li>Tachysystole: Contractions closer than Q2min, or lasting longer than 90 sec, or > 5 contractions in 10 minutes. Repeat in 24 hrs . </li></ul></ul><ul><ul><li>Unsatisfactory: the quality of the tracing is inadequate for interpretation or adequate uterine contractions were not achieved. </li></ul></ul>
    20. 20. Limitations of CST <ul><li>30% false positive == unnecessary premature intervention </li></ul><ul><li>conduct in L+D or adjacent area </li></ul><ul><li>more expensive, time consuming </li></ul><ul><li>must observe after test until uterine activity has returned to baseline activity level </li></ul>
    21. 21. Tachysystole of uterus Too many UC. Rising resting tonus. Positive CST
    22. 22. Key Points for Contraction Stress Test <ul><li>CST now used less frequently </li></ul><ul><li>Uterine contractions produce a reduction in blood flow to the intervillous spaces in the placenta </li></ul><ul><li>A fetus with inadequate placental reserves demonstrates late decelerations in response to hypoxia </li></ul>
    23. 23. Ultrasound <ul><li>Developed in WWII with submarines </li></ul><ul><li>Diagnostic use since 1950s </li></ul><ul><li>Definition: transmission of sound waves to investigate an object </li></ul><ul><ul><ul><ul><li>(Kline-Fath & Bitters, 2007) </li></ul></ul></ul></ul>
    24. 24. Ultrasound <ul><li>Advantages: </li></ul><ul><ul><li>Inexpensive </li></ul></ul><ul><ul><li>Noninvasive </li></ul></ul><ul><ul><li>High degree of patient acceptance </li></ul></ul><ul><ul><li>Yields much information </li></ul></ul><ul><ul><ul><ul><li>(Kline-Fath & Bitters, 2007) </li></ul></ul></ul></ul>
    25. 25. Ultrasound Indications <ul><li>Estimation of fetal age </li></ul><ul><ul><ul><li>Earlier U/S performed, more accurate </li></ul></ul></ul><ul><li>Viability </li></ul><ul><li>Evaluation of fetal growth </li></ul><ul><li>Location of placenta </li></ul><ul><li>Fetal presentation in 3 rd trimester or with multiples </li></ul><ul><li>Anomalies </li></ul><ul><li>Assessment of amniotic fluid volume </li></ul>
    26. 26. Ultrasound con’t <ul><li>Numerous studies show positive effect on maternal bonding with ultrasound experience </li></ul><ul><li>3D U/S especially helpful in facial anomalies </li></ul><ul><li>Nuchal lucency and nasal bone </li></ul><ul><ul><ul><li>Used in combination with maternal serum levels to assess for chromosomal abnormalities </li></ul></ul></ul><ul><ul><ul><ul><ul><li>(Kline-Fath & Bitters, 2007) </li></ul></ul></ul></ul></ul>
    27. 27. Amniotic Fluid Index (AFI) <ul><li>AFI = amount of amniotic fluid measured in largest pocket in each quadrant ( sum of 4 quadrants) </li></ul><ul><li>Normal = 9-10 cm </li></ul><ul><li>Borderline = 5-8cm </li></ul><ul><li>Oligohydramnios < 5cm </li></ul><ul><li>Polyhydramnios > 25cm </li></ul>
    28. 28. Biophysical Profile (BPP) <ul><li>“Intrauterine Apgar Score” </li></ul><ul><li>Combines ultrasound and NST </li></ul><ul><li>Fetal activities observed result from complex processes that are controlled by the CNS </li></ul><ul><li>Activities that are first to develop are last to disappear when asphyxia occurs </li></ul>
    29. 29. <ul><ul><li>1. Reactive NST (within 1 hour of ultrasound portion of test) </li></ul></ul><ul><ul><li>2. Amniotic Fluid: at least one deepest vertical pocket > 2cm </li></ul></ul><ul><ul><li>3. Movement- at least three episodes of gross body movement within a 30 minute period </li></ul></ul>Five Parameters of Biophysical Profile
    30. 30. Five Parameters of Biophysical Profile <ul><ul><li>4. Tone- at least one episode of flexion and extension of an extremity within a 30 minute period </li></ul></ul><ul><ul><li>5. Fetal Breathing Motions- at least 30 seconds within a 30 minute period </li></ul></ul>
    31. 31. Scoring the BPP <ul><ul><li>2 points for each of the criteria met </li></ul></ul><ul><ul><li>0 points if the criteria is not met </li></ul></ul><ul><ul><li>reported as: 0/10, 2/10, 4/10, 6/10, 8/10, or 10/10 </li></ul></ul>
    32. 32. Interpretation of BPP <ul><ul><li>Anytime a (DVP) deep vertical pocket ≤ 2cm, further evaluation is warranted </li></ul></ul><ul><ul><li>score 8/10 (excluding oligo) or 10/10: normal </li></ul></ul><ul><ul><li>score 6/10 : equivocal, repeat within 24 hours </li></ul></ul><ul><ul><li>score 0/10, 2/10, 4/10: delivery is indicated </li></ul></ul>
    33. 33. <ul><li>Keypoints </li></ul><ul><ul><li>A deteriorating fetus will lose in this order : </li></ul></ul><ul><ul><li>-Reactivity </li></ul></ul><ul><ul><ul><li>-Fetal breathing movements </li></ul></ul></ul><ul><ul><ul><li>-Tone </li></ul></ul></ul><ul><ul><ul><li>-Movement </li></ul></ul></ul>
    34. 34. Grading the Placenta
    35. 35. Doppler Studies <ul><li>Definition: </li></ul><ul><ul><li>Non-invasive study of the blood flow in the fetus and the placenta </li></ul></ul><ul><ul><li>Studies the blood flow of the umbilical cord </li></ul></ul><ul><ul><li>More recently may use to look at blood flow in the cerebral artery </li></ul></ul>
    36. 36. <ul><li>Keypoints of Doppler Flow Studies </li></ul><ul><ul><li>Doppler waveform analysis can allow identification of a jeopardized fetus before compromises occur. </li></ul></ul><ul><ul><li>Umbilical artery observed for flow </li></ul></ul><ul><ul><ul><li>Ratio number used to measure flow </li></ul></ul></ul><ul><ul><ul><li>3.5 in normal, can also be intermittently absent or absent </li></ul></ul></ul><ul><ul><ul><li>Reverse diastolic flow is ominous </li></ul></ul></ul>
    37. 37. <ul><ul><li>More Keypoints of Doppler Flow Studies </li></ul></ul><ul><ul><li>The change in frequency is called the “Doppler Shift” </li></ul></ul><ul><ul><li>This shift is computer analyzed and displayed as a velocity waveform </li></ul></ul><ul><ul><li>The frequency of the echoes changes during the systolic and diastolic components of the cardiac cycle </li></ul></ul>
    38. 38. Amniocentesis <ul><li>Trans-abdominal needle aspiration of 10-20 ml of amniotic fluid for lab analysis </li></ul><ul><li>Done under ultrasound </li></ul><ul><li>Requires sterile technique and time out </li></ul>
    39. 39. Amniocentesis <ul><li>Indications: </li></ul><ul><ul><li>Genetic </li></ul></ul><ul><ul><li>R/O infection </li></ul></ul><ul><ul><li>Fetal lung maturity </li></ul></ul><ul><ul><li>Assess for bilirubin with hemolytic incompatibility </li></ul></ul>
    40. 40. Amniocentesis <ul><li>Timing: </li></ul><ul><ul><li>Early – performed between 11-14 wks </li></ul></ul><ul><ul><ul><li>Significantly higher pregnancy loss </li></ul></ul></ul><ul><ul><ul><li>Post procedure fluid loss </li></ul></ul></ul><ul><ul><li>2 nd trimester – performed between 15-20 wks </li></ul></ul><ul><ul><ul><li>Usually for genetic screening </li></ul></ul></ul><ul><ul><li>3 rd trimester </li></ul></ul><ul><ul><ul><li>Usually for fetal lung maturity </li></ul></ul></ul><ul><ul><ul><ul><ul><li>(Gilbert, 4 th edition, pg 93) </li></ul></ul></ul></ul></ul>
    41. 41. Amnioreduction <ul><li>Reduces amount of amniotic fluid around fetus </li></ul><ul><li>Procedure like amniocentesis only with tubing to suction canister or stopcock </li></ul><ul><li>Done to relieve maternal symptoms or with twin to twin transfusion syndrome </li></ul>
    42. 42. Amnioreduction
    43. 43. Fetal Vesicoamniotic Shunt <ul><li>Procedure done for bladder outlet obstruction </li></ul><ul><ul><li>Most common cause is a posterior urethral valve </li></ul></ul><ul><ul><ul><li>Predominantly in males </li></ul></ul></ul><ul><ul><ul><li>Can cause bladder to lose tone </li></ul></ul></ul><ul><ul><ul><li>Hydronephrosis </li></ul></ul></ul><ul><ul><ul><li>Hydroureter </li></ul></ul></ul><ul><ul><ul><li>Can lead to permanent damage if not treated by 20 weeks gestation </li></ul></ul></ul>
    44. 44. Fetal Vesicoamniotic Shunt
    45. 45. Fetal Vesicoamniotic Shunt - echotip needle in bladder
    46. 46. Fetal Vesicoamniotic Shunt – post shunt placement and decompression of bladder
    47. 47. Bilateral Hydronephrosis (enlarged kidneys)
    48. 48. Cordocentesis / Fetal Blood Transfusion <ul><li>Blood Transfusion for anemia </li></ul><ul><ul><li>How much blood is given? </li></ul></ul><ul><ul><li>Graph is used correlating the hematocrit of donor blood to the hematocrit of the fetus to determine donor blood volume to be given </li></ul></ul>
    49. 49. Cordocentesis / Fetal Blood Transfusion
    50. 50. Fetal MRI <ul><li>Superior soft tissue contrast test </li></ul><ul><li>Does not use radiation </li></ul><ul><li>Used for fetal brain, spinal deformities, lesions, masses </li></ul><ul><ul><li>Also can assess placental and cord malformations </li></ul></ul><ul><li>Also used to measure lung volume </li></ul><ul><ul><ul><li>Research still continuing for PPROM pts </li></ul></ul></ul><ul><ul><ul><ul><ul><li>(Kline-Fath & Bitters, 2007) </li></ul></ul></ul></ul></ul>
    51. 51. Fetal MRI Con’t <ul><li>Not recommended in first trimester </li></ul><ul><li>(no documented studies on harm </li></ul><ul><li>from heat or sound, but not recommended) </li></ul><ul><li>Not used routinely, only after U/S not able to detect </li></ul><ul><li>Contrast dye not recommended </li></ul><ul><li>Informed consent </li></ul><ul><ul><ul><li>(Kline-Fath & Bitters, 2007) </li></ul></ul></ul>
    52. 52. Fetal Echocardiogram <ul><li>Timing: between 18-22 weeks </li></ul><ul><li>Indications: </li></ul><ul><ul><li>Family history congenital heart defects </li></ul></ul><ul><ul><li>Maternal diabetes </li></ul></ul><ul><ul><li>Drug exposure </li></ul></ul><ul><ul><li>Teratogenic exposure </li></ul></ul><ul><ul><li>Chromosomal abnormalities </li></ul></ul><ul><ul><li>Non-immune hydrops </li></ul></ul><ul><ul><li>Maternal PKU </li></ul></ul><ul><ul><li>Fetal arrhythmias </li></ul></ul><ul><ul><ul><ul><ul><li>Queenan, Hobbins & Spong (4 th edition, 2007) </li></ul></ul></ul></ul></ul>
    53. 53. THE END