FOR MBBS & OBG students

1. Antenatal assessment of
Fetal well being
• DR RAVIKANTH G O
• ASSOCIATE PROFESSOR
• DEPT OF OBG
• KVG MEDICAL COLLEGE

2. Majority (80%) of fetal deaths
• (i) Chronic fetal hypoxia (IUGR).
• (ii) maternal complications, e.g. diabetes, hypertension,
infection;
• (iii) fetal congenital malformation and
• (iv) unexplained cause.

3. Rationality of Antenatal Fetal Tests
• Tests must provide information superior to that
of clinical evaluation
• Test results should be helpful in management to
improve perinatal outcome
• Benefits of tests must outweigh the potential
risks and the costs

4. The Measures That can be Taken When a Fetus is Found
Compromised
•􏰂 Bed rest 􏰂 Fetal surveillance
• 􏰂 Drug therapy
•􏰂 Urgent delivery of the fetus—term or preterm
•􏰂 Neonatal intensive care (NIC)
•􏰂 Termination of pregnancy for fetal congenital anomaly

5. CLINICAL
EVALUATION OF
FETAL WELL-
BEING AT
ANTENATAL CLINIC
( First Visit)
• History taking
• Go through the records
• Clinical examination
• Antenatal investigations

6. Subsequent visits
• Maternal weight gain:
• Blood pressure:
• Assessment of the size of the uterus and height of the
fundus:
• Clinical assessment of excess liquor
• Documentation of the girth of the
abdomen in the last trimester

8. Gravidogram

9. SPECIAL INVESTIGATIONS
• 30% of antepartum fetal deaths are due to asphyxia (IUGR,
post-dates),
• 30% due to maternal complications (pre-eclampsia, placental
abruption, diabetes mellitus),
• 15% due to congenital malformations and chromosomal
abnormalities and
• 5% due to infection.
About 20% of stillbirths have no obvious cause

10. • About 50% of first trimester spontaneous abortions and
about 5% of stillborn infants have chromosomal
abnormalities.
• Congenital abnormalities may be:
(1) Chromosomal: numerical (47 XXX) or structural
(translocations),
(2) Single gene (cystic fibrosis),
(3) polygenic and multifactorial (NTDs) and
(4) teratogenic disorders (drugs).

11. Other Investigations
Biochemical
biophysical
methods

12. ANTEPARTUM FETAL
SURVEILLANCE
(LATE PREGNANCY)
• 􏰂 Clinical
• 􏰂 Biochemical
• 􏰂 Biophysical

13. BIOPHYSICAL
Hypoxia → metabolic acidosis →
CNS depression → changes in
fetal biophysical activity.

14. Biophysical
tests
• Fetal movement count
• Non-stress test (NST)
• Vibroacoustic stimulation test
• Ultrasonography
• Fetal biophysical profile (BPP)
• Contraction stress test (CST
• Cardiotocography
• Doppler ultrasound
• Amniotic fluid volume

15. Fetal movement
count
• Cardif“count10”formula
• Dailyfetalmovementcount(D
FMC)
• 88% Mothers perceive
• performed daily starting at
28 weeks of pregnancy.

16. Interpretation of
fetal movement
count
• Loss of fetal movements
• Fetal movements may be
reduced
1. Fetal sleep (quiet),
2. Fetal anomalies (CNS),
3. Anterior placenta,
4. Hydramnios,
5. obesity,
6. Drugs (narcotics),
7. Chronic smoking and
8. Hypoxia.

17. Non-stress test (NST)
• FHR acceleration with fetal movements, - healthy fetus.
• Autonomous nervous system

18. Interpretation
of NST
􏰂 Reactive(Reassuring)—
􏰂 Non-reactive (Non-reassuring)—
A reactive NST - perinatal death 5 per 1,000.
NST is nonreactive. perinatal death i40 per 1,000
Testing should be started after 30 weeks
The test has a false negative rate of 0.5% and false positive
rate of 50%.
Vibroacoustic stimulation (VAS)

19. Fetal Biophysical Profile (BPP)

20. Modified Biophysical
Profile
NST and amniotic fluid index
(AFI).
Abnormal - NST is non-reactive
and/ or the AFI is < 5.

21. Fetal Cardiotocography
(CTG):
• Baseline heart rate
• Beat to beat variability
• Accelerations
• Decelerations

22. Ultrasonography:

23. Doppler
Ultrasound
Velocimetry:

25. Table 11.3: Antenatal Doppler Ultrasound Changes and the Suggestive Features of a Compromised Fetus
Vessel Change
Pathophysiological
Basis
Clinical Significance
Umbilical artery (UA)
Reduced or absent or
reversed end diastolic flow
(Fig. 11.2)
Failure of villous
trophoblast invasion (see
p. 37, 39)
↑ resistance in fetoplacental
circulation → IUGR, pre-
eclampsia
Middle cerebral artery
(MCA)
↑ Diastolic velocity;
↓ S/D or Pulsatory index
Dilatation of cerebral
vessels
“Brain Sparing” effect in
response to hypoxemia
Ductus venosus (DV)
↑ Doppler index*; Absent/
Reversed flow (a-wave)
↑ Central venous
pressure (CVP)
Fetal acidemia
Umbilical vein (UV)
↑ Doppler index; Pulsatile
flow
↑ CVP or
↓ Cardiac compliance
Fetal acidemia

26. Contraction stress test (CST)

27. Assessment of fetal pulmonary maturity:
• Estimation of pulmonary surfactant by
lecithin/sphingomyelin (L/S) ratio.
• Shake test or Bubble test :
• Foam Stability Index (FSI)
• Presence of phosphatidyl glycerol(PG)

28. • Saturated phosphatidylcholine ≥ 500 ng/mL
• Fluorescence polarization:
• Amniotic fluid optical density at 650 nm greater than 0.15
• Lamellar body > 30,000/μL

29. • Orange colored cells 0.1% Nile blue sulfate
• Amniotic fluid turbidity:

30. Assessment of severity of Rh–
isoimmunization
• by amniocentesis for estimation of bilirubin in the amniotic fluid
by spectrophotometric analysis.
• optical density difference at 450 nm gives the prediction of the
severity of fetal hemolysis.

31. summary
• Clinical evaluation - Weight,BP,Cardiff count,Daily Fetal
movements count.
• Biochemical - Double marker,Tripple test,Quad test.
• Biophysical -NST, BPP, Modified BPP,Contraction stress test
• Ultrasonogram Biopmetry, doppler of UtA,UA,MCA.
• Pulmonary maturity test.

32. Evaluation
• What are the clinical methods of fetal assessment ?
• What is normal Cardiff count ?
• What is DFKMC ?
• What is the amount of weight gain during pregnancy ?
• What is the principle of NST ?
• What is reactive NST?
• What is positive NST ?

33. • What are the biometry in Ultrasonogram?
• Which vessels doppler are to done ?
• What are the parameter checked in doppler ?
• What are the pulmonary maturity tests ?