ANTENATAL FETAL SURVILLENCE, FETUS, PREGNANCY, OBSTETRICS, FETAL MEDICINE

1. Antenatal Fetal SurveillanceAntenatal Fetal Surveillance
DR. RABI NARAYAN SATAPATHYDR. RABI NARAYAN SATAPATHY
ASST.PROFESSORASST.PROFESSOR
DEPT. OF OBST.& GYNAECOLOGYDEPT. OF OBST.& GYNAECOLOGY
SCB MEDICAL COLLEGE, CUTTACKSCB MEDICAL COLLEGE, CUTTACK
MOB-09861281510MOB-09861281510
EMAIL-drrabisatpathy@gmail.comEMAIL-drrabisatpathy@gmail.com

2. Aim of Fetal MonitoringAim of Fetal Monitoring
Assuming satisfactory growth & wellbeing ofAssuming satisfactory growth & wellbeing of
fetus & mother throughout pregnancyfetus & mother throughout pregnancy
Screening high risk cases & adverse maternalScreening high risk cases & adverse maternal
and/or intrauterine factors which affect the fetusand/or intrauterine factors which affect the fetus
Detecting early congenital anomalies and inbornDetecting early congenital anomalies and inborn
metabolic disorders to decide early terminationmetabolic disorders to decide early termination

3. Known Adverse FactorsKnown Adverse Factors
Early primigravida (> 30 yrs)Early primigravida (> 30 yrs)
Pregnancy above 35 (more Downs Syndrome)Pregnancy above 35 (more Downs Syndrome)
Pregnancy with medical complications likePregnancy with medical complications like
– AnemiaAnemia
– PIHPIH
– Renal diseaseRenal disease
– Cardiac diseaseCardiac disease
– DiabetesDiabetes
– Syphilis, etc.Syphilis, etc.
PET or eclampsia or previous historyPET or eclampsia or previous history
Previous stillbirth or neonatal deathPrevious stillbirth or neonatal death
H/o recurrent abortion or premature labourH/o recurrent abortion or premature labour
Rh – isoimmunisationRh – isoimmunisation
Previous birth of a baby with CNS anomaly likePrevious birth of a baby with CNS anomaly like
anencephaly, open spina bifidaanencephaly, open spina bifida
Previous child with chromosomal abnormality –Previous child with chromosomal abnormality –
Autosomal trisomyAutosomal trisomy
Maternal illness in first trimester like viral infectionsMaternal illness in first trimester like viral infections

4. Objectives of Fetal SurveillanceObjectives of Fetal Surveillance
To determine gestational ageTo determine gestational age
To discover fetal congenital anomaliesTo discover fetal congenital anomalies
To detect abnormalities of fetal growthTo detect abnormalities of fetal growth
To detect & determine the severity of acute &To detect & determine the severity of acute &
chronic fetal hypoxiachronic fetal hypoxia

5. Gestational AgeGestational Age
ClinicalClinical
– LMPLMP
– Initial pelvic examInitial pelvic exam
– FHS 1FHS 1stst
heardheard
Doppler – 10 wksDoppler – 10 wks
Stethoscope – 20 wksStethoscope – 20 wks
– Date of 1Date of 1stst
positive pregnancy testpositive pregnancy test
4 – 5 wks of amenorrhea4 – 5 wks of amenorrhea
USGUSG
– BPDBPD
– Head CircumferenceHead Circumference
– FLFL
– ACAC
– Time – 16 to 20 wks pregnancy. After 30 wks noTime – 16 to 20 wks pregnancy. After 30 wks no
value of discrepancy of more than 1 wk with clinicalvalue of discrepancy of more than 1 wk with clinical
repeat USG after 4 wksrepeat USG after 4 wks
Mean adjusted sonographic age
Estimated fetal wt by Hadlock
circulation

6. Special Investigations in Early PregnancySpecial Investigations in Early Pregnancy
Detect congenital anomaliesDetect congenital anomalies
Chromosomal disordersChromosomal disorders
Sex linked genetic disordersSex linked genetic disorders
Inborn errors of metabolismInborn errors of metabolism

7. USG at 16 -18 wksUSG at 16 -18 wks
To detect structural abnormalityTo detect structural abnormality
– AnencephalyAnencephaly
– HydrocephalyHydrocephaly
– Spina bifidaSpina bifida
Gestational ageGestational age
Detect multiple pregnancy of congenitalDetect multiple pregnancy of congenital
abnormality of fetus is suspected detailed studyabnormality of fetus is suspected detailed study
of all organs doneof all organs done

8. Amniocentesis (14 – 16 wks)Amniocentesis (14 – 16 wks)
Under sonographic guidanceUnder sonographic guidance
DangersDangers
– Trauma to fetus & placentaTrauma to fetus & placenta
– InfectionInfection
– Abortion or preterm labourAbortion or preterm labour
Tests doneTests done
– Estimation ofEstimation of αα-feto protein to detect open neural tube-feto protein to detect open neural tube
defects – Normal 20 mg/lit at 16defects – Normal 20 mg/lit at 16thth
weekweek
– Culture & chromosomal studyCulture & chromosomal study

9. IndicationsIndications
Pregnancy after 35 yrs (Down’s syndrome)Pregnancy after 35 yrs (Down’s syndrome)
Previous child with chromosomal abnormalityPrevious child with chromosomal abnormality
(Autosomal trisomy)(Autosomal trisomy)
X-linked genital disorders. Males more affectedX-linked genital disorders. Males more affected
To detect inborn errors of metabolism if previousTo detect inborn errors of metabolism if previous
child affectedchild affected
If no treatment, termination is advisedIf no treatment, termination is advised

10. Chorionic Villous BiopsyChorionic Villous Biopsy
For prenatal diagnosis of genetic disordersFor prenatal diagnosis of genetic disorders
Carried out 6Carried out 6thth
wk of pregnancy upto end of 1wk of pregnancy upto end of 1stst
trimestertrimester
A few villi collected from chorionic from ------- &A few villi collected from chorionic from ------- &
ultrasonic guidanceultrasonic guidance
AdvantageAdvantage
– Earlier diagnosis as cell culture not requiredEarlier diagnosis as cell culture not required
RisksRisks
– Abortion or infection moreAbortion or infection more

11. Tests DoneTests Done
Cytogenic techniqueCytogenic technique
– Cells cultured for 10 days to 3 wks & chromosomalCells cultured for 10 days to 3 wks & chromosomal
study donestudy done
Enzymatic studyEnzymatic study
Direct analysis of DNA within the chromosomesDirect analysis of DNA within the chromosomes

12. Fetal Blood SamplingFetal Blood Sampling
FetoscopyFetoscopy
– No role now as fetal loss 5%No role now as fetal loss 5%
CordocentesisCordocentesis
– Done at 18 wks of gestation to get fetal cells forDone at 18 wks of gestation to get fetal cells for
karyotyping within 24 hrskaryotyping within 24 hrs
IndicationsIndications
– To establish fetal blood valuesTo establish fetal blood values
– To evaluate hemoglobin concentration in RhTo evaluate hemoglobin concentration in Rh
isoimmunisation & if required, fetal blood transfusionisoimmunisation & if required, fetal blood transfusion
– To detect fetal blood abnormalities like:To detect fetal blood abnormalities like:
HemoglobinopathiesHemoglobinopathies
Genetic diseaseGenetic disease
Fetal infection specially TORCHFetal infection specially TORCH
To diagnose intrauterine fetal hypoxiaTo diagnose intrauterine fetal hypoxia

13. Late PregnancyLate Pregnancy
ClinicalClinical
BiochemicalBiochemical
BiophysicalBiophysical

14. Clinical TestsClinical Tests
Maternal wt gain average 1Kg per fortnightMaternal wt gain average 1Kg per fortnight
– Excess – PETExcess – PET
– Less or stationary – IUGRLess or stationary – IUGR
Blood pressure to detect PIHBlood pressure to detect PIH
Assess of size of uterus & height of fundusAssess of size of uterus & height of fundus
GravidogramGravidogram →→ SymphysisSymphysis →→ fundal ht < 10fundal ht < 10thth
percentilepercentile →→ IUGRIUGR
Clinical impression of excess or less liquorClinical impression of excess or less liquor
– Scanty liquorScanty liquor →→ falling placental functionfalling placental function →→ IUGR,IUGR,
fetal deathfetal death
– Disproportionately enlargedDisproportionately enlarged →→ Twin or HydramniosTwin or Hydramnios
Girth of abdomen in last trimesterGirth of abdomen in last trimester
– Increases steadily upto termIncreases steadily upto term
– If reducesIf reduces →→ Placental insufficiency in high risk casesPlacental insufficiency in high risk cases
such at PET, PIH, BOH & IUGRsuch at PET, PIH, BOH & IUGR

15. Biochemical TestsBiochemical Tests
No clinical use nowNo clinical use now
Two tests may be usedTwo tests may be used
Estimation of urinary or plasma estriol twice weeklyEstimation of urinary or plasma estriol twice weekly
– Advantage in post term pregnancy & PIHAdvantage in post term pregnancy & PIH
– No value in diabetes, multiple pregnancy & RhNo value in diabetes, multiple pregnancy & Rh
incompatibilityincompatibility
– At term, 40-50 mg/ 24 hr urine.At term, 40-50 mg/ 24 hr urine.
Fall of 50% of previous 3 values or < 12 mg in 24 hrsFall of 50% of previous 3 values or < 12 mg in 24 hrs →→ Critical.Critical.
< 4 mg< 4 mg →→ Impending fetal deathImpending fetal death
– Plasma immunoassay < 10Plasma immunoassay < 10 µµg/ 100 ml in last 4 wksg/ 100 ml in last 4 wks
indicates fetal riskindicates fetal risk
Estimation of HPLEstimation of HPL
– Detects functional placentaDetects functional placenta
– < 4< 4 µµg/ml after 30 wks is significantg/ml after 30 wks is significant
– Valuable in PIH, postdated pregnancy & IUGRValuable in PIH, postdated pregnancy & IUGR
– No value in diabetesNo value in diabetes

16. Biophysical TestsBiophysical Tests
HypoxiaHypoxia →→ Metabolic acidosisMetabolic acidosis →→ CNSCNS
DepressionDepression →→ Changes in biophysical activityChanges in biophysical activity
Tests usedTests used
Fetal movement countFetal movement count
NSTNST
UltrasonographyUltrasonography
CardiotocographyCardiotocography

17. Fetal Movement CountFetal Movement Count
Cardif count 10 formulaCardif count 10 formula
– < 10 movements in 12 hrs on successive 2 days or no< 10 movements in 12 hrs on successive 2 days or no
movement in hours in single day indicates fetalmovement in hours in single day indicates fetal
distressdistress
DFMCDFMC
– 3 counts of one hour duration x 4. If < 10 in 12 hrs,3 counts of one hour duration x 4. If < 10 in 12 hrs,
diminished placental function. So NST is adviseddiminished placental function. So NST is advised

18. ObservationsObservations
Baseline heart rate (Normal 120 – 160 bpm)Baseline heart rate (Normal 120 – 160 bpm)
Variability of fetal heart rate (10 – 25 bpm)Variability of fetal heart rate (10 – 25 bpm)
Presence or absence of accelerationsPresence or absence of accelerations
Presence or absence of decelerationsPresence or absence of decelerations

19. NSTNST
Response of fetal heart to fetal movement doneResponse of fetal heart to fetal movement done
by cardiotocographyby cardiotocography
ReactiveReactive →→ 2 or more acceleration of 15 bpm2 or more acceleration of 15 bpm
lasting for more than 15 sec in 20 min with fetallasting for more than 15 sec in 20 min with fetal
movementmovement
If no acceleration, continue for 40 min to confirmIf no acceleration, continue for 40 min to confirm
non-reactionnon-reaction
If reactive, fetal demise chance < 1% in 1 wkIf reactive, fetal demise chance < 1% in 1 wk
So, weekly monitoring requiredSo, weekly monitoring required
But in cases of IUGR, postmaturity & diabetes,But in cases of IUGR, postmaturity & diabetes,
done twice a weekdone twice a week

20. CSTCST
By oxytocin stress test or nipple stimulation testBy oxytocin stress test or nipple stimulation test
Contraindicated in preterm labour, previous CS,Contraindicated in preterm labour, previous CS,
APHAPH
Oxytocin drip started at 0.5 mU/min, double inOxytocin drip started at 0.5 mU/min, double in
every 15-20 min interval till 3 contractions lastingevery 15-20 min interval till 3 contractions lasting
for 40-60 sec occur in 10 minfor 40-60 sec occur in 10 min
Time taken 1½ - 2 hrsTime taken 1½ - 2 hrs
No hypoxiaNo hypoxia →→ FHR pattern uncharged duringFHR pattern uncharged during
contractioncontraction
HypoxiaHypoxia →→ FHR slows down with decelerationFHR slows down with deceleration
– Late deceleration is significantLate deceleration is significant

21. VASTVAST
Done to avoid fetal sleepDone to avoid fetal sleep
– < 24 wks< 24 wks →→ No responseNo response
– 24 – 27 wks24 – 27 wks →→ 30% respond30% respond
– 27 – 30 wks27 – 30 wks →→ 86% respond86% respond
– > 31 wks> 31 wks →→ 96% respond96% respond

22. Biophysical Profile Score (BPS)Biophysical Profile Score (BPS)
Manning et al (1980)Manning et al (1980)
Combined with NST & CTGCombined with NST & CTG
ParametersParameters
– NSTNST
– Fetal breathing movementFetal breathing movement
– Gross body movementGross body movement
– Fetal toneFetal tone
– Amniotic fluid volumeAmniotic fluid volume

23. VariableVariable Score – 2Score – 2 Score – 0Score – 0
Fetal reactivityFetal reactivity
> 2 FHR> 2 FHR
accelerationacceleration
No or < 2No or < 2
accelerationacceleration
Fetal breathingFetal breathing
movementmovement
At least 1 of > 30At least 1 of > 30
secsec
No FBM or < 30 secNo FBM or < 30 sec
Fetal movementFetal movement
(Gross body(Gross body
movement)movement)
> 3 discrete GBM> 3 discrete GBM < 2 or nil< 2 or nil
Fetal toneFetal tone
At least one episodeAt least one episode
of limb flexion toof limb flexion to
rapid extensionrapid extension
No limb movement orNo limb movement or
slow flexionslow flexion
Amniotic fluid volAmniotic fluid vol
> 1 pocket of > 1 cm> 1 pocket of > 1 cm
depth in twodepth in two
perpendicular planeperpendicular plane
Largest pocket < 1Largest pocket < 1
cm in twocm in two
perpendicular planesperpendicular planes

24. InterpretationInterpretation
Score – 10Score – 10 →→
– Conservative managementConservative management
– Repeat after 1 wk or after 3 days in IUGR, diabetes,Repeat after 1 wk or after 3 days in IUGR, diabetes,
postmaturitypostmaturity
Score – 8Score – 8 →→
– Liqour normal, manage as beforeLiqour normal, manage as before
– If less or postmaturityIf less or postmaturity →→ DeliverDeliver
Score – 6Score – 6 →→ EquivocalEquivocal
– Repeat test after 24 hrsRepeat test after 24 hrs
– If sameIf same →→ DeliverDeliver
Score – 4 or lessScore – 4 or less →→ AbnormalAbnormal
– Immediate delivery except when fetus is grosslyImmediate delivery except when fetus is grossly
immatureimmature
Modified BPSModified BPS →→ Placental grading considerPlacental grading consider
– If premature agingIf premature aging →→ Fetal compromiseFetal compromise

25. Doppler UltrasonographyDoppler Ultrasonography
UterineUterine
UmbilicalUmbilical
Internal carotid arteryInternal carotid artery
Cerebral vesselsCerebral vessels
Peak systolic & end diastolic blood flowPeak systolic & end diastolic blood flow
measuredmeasured
Systolic: Diastolic < 3 is normal in umbilical &Systolic: Diastolic < 3 is normal in umbilical &
uterine arteryuterine artery
Lack of diastolic component or reversal diastolicLack of diastolic component or reversal diastolic
blood flow is ominous sign.blood flow is ominous sign.

26. Amniocentesis in Late PregnancyAmniocentesis in Late Pregnancy
Pulmonary maturityPulmonary maturity
Assessment of severity of Rh-isoimmunisationAssessment of severity of Rh-isoimmunisation
Maturity of fetus by Nile blue testMaturity of fetus by Nile blue test
Orange cells > 50% mature fetusOrange cells > 50% mature fetus

27. Pulmonary MaturityPulmonary Maturity
αα / S ratio > 2/ S ratio > 2
Identification of phosphotidyl glycerolIdentification of phosphotidyl glycerol
O.D at 650O.D at 650 µµ > 0.15> 0.15
Shake test or bubble testShake test or bubble test →→ Diluted amnioticDiluted amniotic
fluid & 96% ethanol shake for 15 sec & inspectfluid & 96% ethanol shake for 15 sec & inspect
after 15 minafter 15 min

28. Assessment of Severity ofAssessment of Severity of
Rh-isoimmunisation (30 – 32 wks)Rh-isoimmunisation (30 – 32 wks)
Antibody titer rises > 1:8Antibody titer rises > 1:8
Previous history of severely affected or stillbirthPrevious history of severely affected or stillbirth
or requiring exchange transfusionor requiring exchange transfusion
If father hetera & to know baby is affected or notIf father hetera & to know baby is affected or not