Non-invasive methods:USG,NST Non invasive & Invasive methods: Chorionic villus sampling Amniocentesis Fetoscopy MSAFP: maternal serum alpha feto protein. Others includes Cordocenthesis, Amnioscopy

1. NEWER MODALITIES OF
PREGNANCY- INVASIVE
AND NON INVASIVE
KHUSHBU PATEL
GCS SCHOOL/COLLEGE
OF NURSING

2. INTRODUCTION
• Many changes occur in woman’s body during
pregnancy. These changes although most
apparent in the reproductive organs, involve
other body systems as well.
• Weeks may pass before the family realizes
she has become pregnant or she may learn
upon a visit to a doctor for other reasons
• Confirmation her pregnancy is most important
for the health & welfare of herself & the baby.
In this lesson, we will cover the tests used to
determine pregnancy

3. RISK APPROACH SCREENING
• Blood testing
• Excessive weight gain of the mother due to
fluid retention. Falling weight also poses risk as
there can be intrauterine growth retardation.
• Pre-existing hypertension or PIH
• Excess amount or decreased amount of
amniotic fluid is another risk factor.
• Other approaches, which should be followed
for high-risk cases, are: non-invasive &
invasive methods are used

4. • Non-invasive methods:
• Examination of the woman’s uterus from
outside the baby.
• Listening to the fetal heart sound
• External fetal monitoring
• It includes: Ultrasonography,
• Cardiotocography,
• Non- stress test,
• Contraction stress test,
• amniotic fluid index

5. • Invasive methods:
• Chorionic villus sampling
• Amniocentesis
• Fetoscopy
• MSAFP: maternal serum alpha feto
protein.
• Others includes Cordocenthesis,
Amnioscopy.

6. OBJECTIVE OF INVASIVE &
NONINVASIVE DIAGNOSIS
• To reduce maternal and fetal mortality rate.
• To check fetal growth and development.
• To enable timely medical or surgical treatment
of a condition before or after birth,
• To give the parents the chance to abort a
fetus with the diagnosed condition,
• To give parents the chance to "prepare"
psychologically, socially, financially, and
medically for a baby with a health problem or
disability, or for the likelihood of a stillbirth

7. Common indicators of invasive
& noninvasive diagnosis:-

8. • 1) ULTRASONOGRAPHY
• 2) CARDIOTOCOGRAPHY
• 3) NON STRESS TEST
• 4) CONTRACTION STRESS TEST
• 5) AMNIOTIC FLUID INDEX (AFI)
NON-INVASIVE METHODS OF
DIAGNOSIS

9. ULTRASONOGRAPHY (USG)
• An ultrasonography is a diagnostic technique,
which uses high-frequency sound waves to
create an image of the internal organs.
• A screening ultrasound is sometimes done
during the course of a pregnancy to check
normal fetal growth and verify the due date.
• It is a safe , non invasive, accurate and
cost effective investigation
• Hard tissues such as bone appear white on
the image and soft tissues appear grey.

11. Indications:
• In the first trimester:
• To establish the dates of a pregnancy
• To determine the number of fetuses and identify
placental structures
• To diagnose an ectopic pregnancy or
miscarriage
• To examine the uterus and other pelvic
anatomy
• In some cases to detect fetal abnormalities as
anencephaly

12. • Mid-trimester: (sometimes called the 18 to 20 week
scan)to confirm pregnancy dates or gestational age
• To determine the number of fetuses and examine the
placental structures
• To assist in prenatal tests such as an amniocentesis,
Cordocenthesis .
• To examine the fetal anatomy for presence of
abnormalities
• To check the amount of amniotic fluid by measuring
AFI.
• To examine blood flow patterns
• To check on the location of placenta; to see if its
covering cervix
• To observe fetal behavior and activity

13. • Third trimester:
• To monitor fetal growth, to check
IUGR
• Detailed anatomical survey.
• To check the amount of amniotic
fluid
• to determine the position of a fetus
• To assess the placenta

14. types of ultrasounds performed
during pregnancy
Abdominal
ultrasound
Transvaginal
ultrasound

15. Abdominal ultrasound
• In an abdominal ultrasound, gel is applied
to the abdomen and the ultrasound
transducer glides over the gel on the
abdomen to create the image

16. TRANSABDOMINAL USG

17. TRANSVAGINAL ULTRASOUND
• a smaller ultrasound transducer is inserted
into the vagina and rests against the back
of the vagina to create an image.
• A transvaginal ultrasound produces a
sharper image and is often used in early
pregnancy.

18. TRANSVAGINAL USG

19. • Indication of transvaginal ultrasound:-
• Early month of pregnancy
• In this high frequency of sound waves used so
greater resolution is possible
• Typical gynaecological indication includes
uterine size, evaluation of endometrium,
myometrium, cervix
• Contraindication:-
• Allergy to latex.
• Vaginal infection

20. Nursing responsibility before
procedure
• Explain the purpose of procedure and how it
will be done.
• Advise for drink lots of water so that full
bladder to capture clearer images
• Provide privacy.
• Provide supine position . (dorsal position).
• The abdominal wall is prepared and draped.
• Check USG

21. Procedure :
• TRANS ABDOMINAL USG:-
• Explain the procedure to the patient.
• Provide privacy
• Provide supine position to the patient.
• Apply gel

22. Transvaginal USG
• A probe is placed into the vagina instead of
over the abdomen.
• Provide dorsal lithotomy position with empty
bladder.
• Vaginal probe should be lubricated with gel and
the probe should be inserted in to an
appropriate covering sheeth such as condom
• The sheath covered probe is gently advanced
up the vaginal canal
• If ultrasound is done before the week 11, it
would be transvaginal

23. Safety of USG
• Ultrasounds bring no long term or short-term
harm to both mother and baby.
• In fact, it is a useful scanning tool. Because the
waves are of very low intensity, there is no
danger in repeating the scans, if your condition
merits it.
• However if pregnancy is normal, then 2 routine
scans as part of antenatal care.
• More scans are only necessary if any medical
condition

24. Advantage of USG
• Complex structure can be viewed in a single
image.
• Stored data can be reviewed at any plane
later on without needing the patient, this helps
to get second opinion if required.
• Prenatal diagnosis of certain anomalies is
improved.
• Photo of 3- Dimensional image improves
antenatal parental bonding and important
teaching tool.

25. CARDIOTCOGRAPHY
• Cremer first demonstrates this method in
1904. In this test, Fetal Heart Rate and
uterine contraction are graphically
recorded. It is generally performed in third
trimester.
• The machine used to perform the
monitoring FHR called a cardiotocograph
or electronic fetal monitor or external fetal
monitor

26. CARDIOTOCOGRAPH

27. CARDIOTOCOGRAPH

28. Procedure

29. • INTERPRETATION
• A typical CTG output for a woman not in
labour. A: Fetal heartbeat; B: Indicator showing
movements felt by you (caused by pressing a
button); C: Fetal movement; D: Uterine
contractions

30. Advantages:-
• Help to detect
hypoxia in early
stage.
• Reduce fetal
death
• It is important
record for
medico-legal
purpose
Drawback
• Instrument is
expensive and
trained person are
required to
interpret.
• Mother has to
confined in bed
• Due to false
prediction
caesarean section
rate may be high

31. Non-stress Test ( NST)
• Non-stress test is a simple, painless procedure
in which a baby's heartbeat is continuously
monitored for 20 minutes or more along with
recording fetal movement.
• The logic behind the test is, that like adults, a
baby's heartbeat should accelerate when it is
active i.e. moving and kicking.
• Principle : there is acceleration of fetal heart
rate with each fetal movement

32. Performing time:-
• The Non-stress test can be done
whenever the need arises so there is
no specific time for it. around 30
weeks

33. Indications of NST
• Women with preexisting medical conditions
such as diabetes.
• Women with pregnancy-induced medical
conditions such as hypertension
• Baby is less active than normal
• Baby is small for its age
• Amniotic fluid is either too much or too little
• Women who have previously lost their babies
in the second half of their pregnancies
• Women with pregnancies continuing after week
40 to basically check on the well- being of baby

34. Nursing responsibility
• Explain procedure before performing test.
• Informed consent should be given prior to
testing, and a woman has the right to
refuse this test if she chooses
• Provide lateral position or semi fowler or
sitting position to the women.
• the recording is obtained with the patient
lie down on left side, or lateral recumbent
position. ( to avoid supine hypotension)

35. Procedure

36. Contd…
• Two electronic devices will be strapped to
mother abdominal.
• The transducer ultrasound will monitor baby's
heartbeat.
• The other device will record any uterine
contractions felt by the mother.
• While fetal movement is recorded by mother by
pressing a button which makes the mark on the
strip.
• If there are no movements, the fetus is
stimulated manually or may be with a buzzer
• The test takes about 20 minutes to an hour

37. Interpretation
• Reactive test (normal NST) :- NST is called
reactive if there are at least 2 fetal movements
in 20 minutes with acceleration of FHR by 15
beats/min for atleast 15 seconds
• Non-reactive: absence of any fetal reactivity.
It is associated with poor fetal and neontatal
outcome, but there is high incidence of false
positive results also. This may be due to fetal
sleep, sedative or narcotic drugs, congenital
anomalies and premature fetus

38. Procedure :-

39. • Advantages: -
• It is a non-invasive test.
• The test is simple, inexpensive and takes
less time.
• There are no contradictions or
complications
• No special expertise required
• Provide immediate answer.
• It can be repeated as many times as
required without any risk.

40. CONTRACTION STRESS TEST
• Tests will be carried out to analyze the baby's
well being
• CST is based on the observation that during
contractions, blood flow to the placenta lessens
temporarily. An evaluation is done on how the
fetus handles this stress.
• Normally fetal heart rate is not affected by
contractions

41. • In actual labor after contraction begins, if the
fetal heartbeat slows down, it indicates that
the fetal is not able to tolerate the decreased
blood flow resulting from the contraction.
• These decreases are called late
decelerations.
• If the placenta is not working to capacity or
the baby has some problem, Contraction can
decrease the oxygen flow and cause the
heart rate to drop.

42. • Performing time: after 30 weeks
gestation
• Position:-
• Semi recumbent position
• Lateral position

43. Indication:
• It is usually conducted if the pregnant
woman has had problematic pregnancies in
the past or has medical problems in her
current pregnancy.
• CST is usually performed if Non-stress test
showed no change in fetal heart rate when
the fetus moved.
• To check baby will remain healthy during the
reduced oxygen levels that normally occur
during contraction

44. Procedure
Two fetal monitors will be strapped to the
woman's abdomen to record fetal heart rate.
• One monitor will pick up uterine contractions
and the other picks up fetal heart beat. . Both
will readings will record on graph paper.
• Stimulate contraction by either nipple
stimulation or oxytocin.
• Assess the maternal B.P every 10 to 15 min
during the test.

46. •The heartbeat will form a line at the top and the
maternal contractions will form wavelike lines at
the bottom. Both lines will be matched to
determine the significance of any decelerations

47. Result/ Interpretation
• Negative- no late decelerations are present in
the presence of adequate contractions, the
placenta is functioning properly and the fetus
is doing well. It is the desired result
• Positive: late decelerations are present in the
presence of adequate contractions. Delivery
of baby follows a positive result either by
induction of labour or LSCS

48. Amniotic fluid index
• Amniotic fluid index (AFI) is a rough
estimate of the amount of amniotic fluid
and is an index for the fetal well-being.
• AFI is the score (expressed in cm) given to
the amount of amniotic fluid seen on
pregnant uterus and calculated by a
ultrasonograph ( ultrasound).

49. • To determine the AFI, doctors may use
a four-quadrant technique , when the
deepest, unobstructed, vertical length of
each pocket of fluid is measured in each
quadrant and then added up to the
others , or the so called "Single
Deepest Pocket" technique

51. INVASIVE METHODS
• MATERNAL ALPHA-FETOPROTEIN
• AMNIOCENTESIS
• CHORIONIC VILLUS SAMPLING (CVS)
• CORDOCENTHESIS OR
PERCUTANEOUS UMBLICAL CORD
BLOOD SAMPLING (PUBS)
• FETOSCOPY
• AMNIOSCOPY

52. Maternal alpha-fetoprotein
screening (MAFP)
• A blood test that measures the level of alpha-
fetoprotein in the mothers' blood during
pregnancy.
• AFP is a fetal protein normally produced by
the fetal liver and is present in the fluid
surrounding the fetus (amniotic fluid), and
crosses the placenta into the mother's blood.
• The AFP blood test is also called MSAFP
(maternal serum AFP

53. Abnormal levels of AFP may signal
the following
MSAFP level high
indicates:-
Open neural tube defects
(ONTD) such as spina
bifida
• Other chromosomal
abnormalities lead to IUFD
• Defects in the abdominal
wall of the fetus
• Twins more than one fetus
is making the protein
• A miscalculated due date
• Renal anomalies.
MSAFP level low indicates
• Down’s syndrome
• Gestational trophoblastic
disease

54. INDICATION
• All pregnant women are usually offered the
AFP test. But, the doctor may recommend
the test, especially if :
• Mother is 35 or older
• Have a family history of birth defects
• Have diabetes
• Have taken certain drugs or medication
during pregnancy

55. • Time of performing test:- 15-18 weeks
• PROCEDURE:

56. Amniocentesis:-
• It is a medical procedure used in prenatal
diagnosis of chromosomal abnormalities
and fetal infections.
• In which a small amount of amniotic fluid,
which contains fetal tissues, is extracted
from the amniotic sac surrounding a
developing fetus , and the fetal DNA is
examined for genetic abnormalities.

57. • Definition:-it is deliberate puncture of the
fluid sac per abdomen.
• Indication :-
DIAGNOSTIC
THERAPUETIC
EARLY
LATER

58. • Time of performing:- performed
between the 15th-20th weeks of
pregnancy. Mostly during the 18th
week.

59. Nursing responsibility before procedure
• Before procedure, take written consent.
• Explain the purpose of procedure
• Emptying the bladder AND Provide privacy.
• Provide supine position with elevated head
• The abdominal wall is prepared aseptically and
draped.
• Check the vital sign and FHR to obtain base line data.
• Check USG.
• Prophylactic administration of 100 mg of anti –D
immunoglobulin in Rh negative mother.
• The proposed site of puncture is unfiltered with 2 ml
of 1% lignocainE

60. Procedure

61. • Nursing responsibility after procedure:
• Fetus should be monitored for short period
after procedure, check FHR every 30
minutes.
• Tell patient, to report physician if uterine
cramping, vaginal bleeding or leakage of fluid
or fever.
• Strenuous activities should be avoided for 24
hours following an amniocentesis

62. Contraindication:-
• Acute skin infections near the site of
needle placement.
• Maternal fever
• Allergies to material used like skin
preparation materials, local
anesthesia.
• May be difficulty in-patient with
multiple pregnancies

63. COMPLICATION
Maternal complication
• Infection
• Alloimmunisation of the
mother
• Preterm labor and
delivery
• Hemorrhage
Fetal complication
• Miscarriage
• Respiratory distress,
• Postural deformities,
• Fetal trauma.
• Oligohydramnions due to
leakage of Amniotic fluid

64. Chorionic villus sampling CVS
• Chorionic villous sampling a form of
prenatal diagnosis to determine
chromosomal or genetic disorders in the
fetus .
• It entails getting a sample of the chorionic
villus (placental tissue) and testing it.
• It can be performed in a transvaginally or
transabdominal manner

65. Chorionic villus sampling CVS

66. • Performing time: before 15 weeks, usually
performed between the 10th and 12th weeks of
pregnancy.
• Indications:-
• Abnormal first trimester screen results
• Increased AFP or other abnormal ultrasound
findings
• Family history of a chromosomal abnormality or
other genetic disorder
• Parents are known carriers for a genetic
disorder
• maternal age above 35

67. Procedure
• TRANSVAGINALLY:

68. TRANSABDOMINALLY

69. • Contraindication :-
• Active vaginal bleeding
• Infection
• Multiple gestation
• HIV infection

71. • Nursing responsibility after procedure:-
• Fetus should be monitored for short period
after procedure, check FHR every 30 minutes.
• Tell patient, to report physician if uterine
cramping, vaginal bleeding or leakage of fluid
or fever.
• Strenuous activities should be avoided for 24
hours following a CVS.
• Anti –D immunoglobulin 50 ug IM should be
administered following the procedures to the
Rh negative women’s

72. • Complications :-
• Miscarriage in CVS in about 0.5 - 1%.
• Infection and amniotic fluid leakage. The
resulting amniotic fluid leak can develop into
a condition known as oligohydramnions
• Mild risk of Limb Reduction Defects
associated with CVS, especially if the
procedure is carried out in earlier terms
(before 12th week of pregnancy).
• Fetal loss.
• Infection
• Vaginal bleeding

74. Cordocenthesis OR
Percutaneous umbilical cord
blood sampling (PUBS)
• It is a diagnostic genetic test that examines
blood from the fetal umbilical cord to detect
fetal abnormalities.
• PUBS provides a means of rapid chromosome
analysis and is useful when information cannot
be obtained through amniocentesis, CVS, or
ultrasound
• Time of performance:-18 weeks of gestation

75. Procedure
• PUBS is similar to amniocentesis, but instead
of sampling the amniotic fluid which surrounds
the fetus, PUBS examines fetal blood

76. • Before the start of the procedure, a local
anesthetic is given to the mother.
• After the local is in effect, a 25 gauze spinal
needle 13 cm in length is usually inserted
through the mother's abdominal wall,
• An advanced imaging ultrasound determines
the location for needle insertion, and the
needle is guided through the mother's
abdomen and uterine wall into the fetal vein of
the umbilical cord, approximately 1-2 cm from
the placenta.
• The sample can then be sent for
chromosomal analysis.

77. COMPLICATIONS
• Miscarriage is the primary risk associated
with PUBS
• Blood loss at the puncture site,
• Infection, and
• Premature rupture of membranes.
• During the procedure, the mother may feel
discomfort similar to a menstrual cramp.
• Cord hematoma formation
• Preterm labor

78. FETOSCOPY
• A fibreoptic instrument that can be passed
through the abdomen of a pregnant woman to
enable examination of the fetus and
withdrawal of blood for sampling in prenatal
diagnosis.
• DEFINITION
• Examination of the pregnant uterus by means
of a fiber-optic tube.
• Time of performing:-18th week of pregnancy

80. • Complication :-
• Miscarriage, as high as 12%.
• Excessive bleeding, infection, or excessive
leakage of the amniotic fluid.
• Preterm rupture of the membranes which
may require early delivery of your baby .
• Mixing your blood with babys blood

81. AMNIOSCOPY
• Definition
• Direct observation of the foetus and the colour
and amount of the amniotic fluid by means of
a specially designed endoscope inserted
through the uterine cervix.
• Contraindicated:-
• Cervix is in insufficiently dilated
• Complication:-
• Sepsis
• Rupture of membrane

84. ANY QUESTIONS????