An excellent reading material for antepartum fetal health assessment and surveillance for medical and graduate students.

1. Antepartum Fetal Surveillance
Prepared By: Hale T., O & G Resident,
Mekelle University,
College of Health Sciences, Dep't of OB-GYN
23 Dec. 20161Hale T., M.D., Resident Physician

2. • Contents
1. Objectives
2. Introduction
3. Methods of Monitoring Fetal Health3. Methods of Monitoring Fetal Health
4. Principles of Ideal Fetal Testing
5. The Gradual Hypoxia Model
6. Fetal Behavior
7. Biophysical Profile
8. Practical Aspects of Fetal Testing
9. Summary
2Hale T., M.D., Resident Physician

3. 1. Objectives
• The objectives of this presentation are:
– To understand the range of normal fetal
behaviors
– To explain components of BPP and
understand their interpretationunderstand their interpretation
– To discuss hemodynamics and significance
of different Doppler velocimetry studies
– To appreciate the role of fetal assessment in
prevention of fetal death and avoidance
of unnecessary interventions
3Hale T., M.D., Resident Physician

4. 2. Introduction
• Definition
– AFS is assessment of the wellbeing of the
fetus/fetuses during pregnancy especially after the
fetus is considered viable
• Many clinical and basic science researches has
described normal and abnormal fetal behaviordescribed normal and abnormal fetal behavior
• These observations have aided the
development of antenatal tests to distinguish
healthy fetuses from potentially compromised
fetuses
• Primary goal
– to decrease perinatal morbidity and mortality
4Hale T., M.D., Resident Physician

5. Perinatal Moratlity
Hale T., M.D., Resident Physician 5

6. • Antepartum fetal death is much more
common than intrapartum fetal death,
and unexplained fetal death occurs far
more commonly than unexplainedmore commonly than unexplained
infant death
• This justifies for the use of some form
of antepartum fetal health assessment!
Hale T., M.D., Resident Physician 6

7. • Understanding normal fetal physiology and
development is an important part of interpreting
the results of fetal assessment
• A change in fetal behavior implies a change in
fetal status
• Fetal assessment methods based on this tenet
includeinclude
– Maternal evaluation of fetal activity,
– Nonstress testing,
– The use of ultrasound to assess the fetal
biophysical profile (BPP)
– Modified BPP
– Contraction Stresst Tests
– Doppler Velocitymeter 7Hale T., M.D., Resident Physician

8. 3. Methods of Monitoring Fetal Health
• Types of antenatal fetal surveillance
– Fetal Movement
– NST and CST
• The first developed tests• The first developed tests
• Good prediction in nonaspyxiated babys
– Biphysical Profile
• Since 1970
• NST and real time US assessment
– Modified Biophysical Profile
8Hale T., M.D., Resident Physician

9. • BPP Score = APGAR score
of a neonate = Vital signsof a neonate = Vital signs
of an adult!
Hale T., M.D., Resident Physician 9

10. Hale T., M.D., Resident Physician 10

11. • Modified Biophysical Profile
– Components
• NST
• AFV• AFV
– False negative  0.08 /1000
– False positive  60 %
Hale T., M.D., Resident Physician 11

12. 4. Principles of Ideal Fetal Monitoring
• Ideal monitoring system
1. Gathers a wide range of information
2. Detects fetal peril
3. Has a low false-positive rate
4. Has high and durable negative predictive value4. Has high and durable negative predictive value
5. High sensitivity for modest compromise
6. Incorporates multiple variables
7. Detects fetal compromise from a variety of
sources
8. Applicable in inpatient and outpatient settings
9. Has measurable benefits for high-risk
populations 12Hale T., M.D., Resident Physician

13. 5. The Gradual Hypoxia Model
• Fetal biophysical activities are not
random events
• Controlled by specific centers in the
brainbrain
• Presence of such complex biophysical
activities indicates a functioning,
nonhypoxemic CNS
13Hale T., M.D., Resident Physician

14. – The lack of normal biophysical activity may
be due to hypoxia => comatose Fetus
– Abnormal score may occur in a healthy fetus
in the resting phase of a normal sleep–wake
cycle
– Clinical significance of an absent biopysical
cycle
– Clinical significance of an absent biopysical
activity is directly related to the time the
fetus is observed
– The observation time must exceed the
average period of a given sleep state
(about 20 minutes) and ideally should be
at least 1.5 times as long, or 30 minutes
14Hale T., M.D., Resident Physician

15. – Individual CNS centers that may regulate the
biophysical activities appear to vary in their
sensitivity to hypoxia
– Activities that first appear embryologically are
the last to disappear with progressively
worsening hypoxia
– Appearance:– Appearance:
• FT (7.5-8.5 weeks) => FM (9 weeks) => FB
(20-21 weeks) => FHR-R (28 weeks)
– Disappearance:
• FHR-R => FB => FM => FT
15Hale T., M.D., Resident Physician

16. • Proposed fetal CNS centers for biophysical
activities
16Hale T., M.D., Resident Physician

17. • Tone and movement observable in the first
trimester and
• Breathing observable at 21 weeks and beyond
• The presence of normal fetal muscle tone, gross
body movements, and breathing have been
reliably tied to the absence of fetal hypoxemia
and acidemia, which is the basis for the BPP
5. Fetal Behavior
reliably tied to the absence of fetal hypoxemia
and acidemia, which is the basis for the BPP
• By the beginning of the third trimester,
behavioral states 1F to 4F can be defined
17Hale T., M.D., Resident Physician

18. • State 1F
• Quiet sleep (Quiescent State)
• Rapid eye movements and
• Repetitive mouthing movements
• Narrow oscillatory bandwidth of the fetal
heart rateheart rate
• All other movements are absent
• State 2F
• Active sleep (REM in neonates)
• Movements are grouped
• Wider oscillation of the fetal heart rate
18Hale T., M.D., Resident Physician

19. • State 3F
• Quiet awake is unusual
• Short and is seldom observed before term
• Continuous eye movements in the absence
of body movements and no heart rate
accelerations
• Its existence is disputed• Its existence is disputed
• State 4F
• Active awake,
• The “jogging fetus”
• State of high level of voluntary activity and a
sustained high heart rate,
19Hale T., M.D., Resident Physician

20. • Fetal Heart Rate Changes During Development
• As gestation advances,
• The fetal heart rate (FHR) is increasingly
dominated by the parasympathetic system,
• This leads to
• Gradual decrement in FHR• Gradual decrement in FHR
• Increase in variability
• Increase in responsiveness to acute changes
in fetal status including accelerations and
decelerations
20Hale T., M.D., Resident Physician

21. • Fetal movement accelerates heart rate
• Linked to fetal oxygenation and metabolic
status
• This provides the basis for nonstress
testing
21Hale T., M.D., Resident Physician

22. • Fetal Movement Count
• Count 10’ formula:
• Abnormal if
• Less than 10 movements occur during
12 hours on 2 successive days or
• No movement is perceived after 12• No movement is perceived after 12
hours in a single day
• Daily fetal movement count (DFMC)
• Abnormal if
• Less than 10 in 12 hours or
• Less than 3 in each hour
22Hale T., M.D., Resident Physician

23. • Fetal Movement Count cont'd
– The Cardiff methods
• Mother count FM once/day
• <10 movement over 12 hours is alarming
– Rayburn method– Rayburn method
• Count once per day for 60 minutes
• <3 movement/1 hour for two consecutive days is
alarming
– Sadovsky method
• Mother count FM 2-3 times daily
• <3 movement/1 hour is alarming
23Hale T., M.D., Resident Physician

24. • Fetal Movement Count
• Mothers perceive 88% of the fetal movements
detected by Doppler Imaging
• The count should be performed daily starting
at 28 weeks of pregnancy
• Loss of fetal movements is commonly
followed by disappearance of FHR within nextfollowed by disappearance of FHR within next
24 hours
• Maternal hypoglycemia is associated with
increased fetal movements
• Peak time for fetal movement
•  9:00 pm – 1 : 00 am.
• No strong recommendation to use fetal movement count to prevent
fetal death
24Hale T., M.D., Resident Physician

25. Hale T., M.D., Resident Physician 25

26. Hale T., M.D., Resident Physician 26

27. • Maternal perception of fetal movements
may be reduced with
– Fetal sleep (quiet),
– Fetal anomalies (CNS),
– Anterior placenta,– Anterior placenta,
– Hydramnios,
– Obesity, parity and psychological factors
– Drugs (narcotics, phenobarb, Propranolo),
– Chronic smoking and
– Hypoxia
27Hale T., M.D., Resident Physician

28. • Fetal Heart Rate Monitoring
• Couples fetal neurologic status to
cardiovascular reflex responses
• The most sensitive, shorter-term predictor of
worsening hypoxemia or acidosis
28Hale T., M.D., Resident Physician

29. • Nonstress testing
• Combination of fetal movements and FHR
acceleration provides the basis of the
nonstress test (NST)
• Reactive/Reasuring/Negative
• Good
• Nonreactive/Noreasuring/Positive• Nonreactive/Noreasuring/Positive
• Bad
• Different for term and preterm
• Term: 2 accelerations / amplitude of 15 beats/15
seconds/in 20-30 minutes
• Preterm: 2/15 beats/10 seconds/30minutes
29Hale T., M.D., Resident Physician

30. • NST (Cont'd)
• There is an observed association of FHR
acceleration with fetal movements, which when
present, indicates a healthy fetus
• The test is valuable to identify the fetal wellness
rather than illness
• A reactive NST is associated with perinatal death• A reactive NST is associated with perinatal death
of about 5 per 1000
• But perinatal death is about 40 per 1000 is when
the NST is nonreactive
• Testing should be started after 30 weeks and
frequency should be twice weekly
• The test has a false negative rate of 0.5% and
false positive rate of 50% 30Hale T., M.D., Resident Physician

31. • Duration of monitoring
• Ranges 10-60 minutes
• In the context of the BPP, 30 minutes is
allowed for the NST to demonstrate reactivity
• About 10% to 12% of fetuses in the third
trimester do not meet these criteria at 30trimester do not meet these criteria at 30
minutes
• This number falls below 6% by 40 minutes
• The most common explanation for a
nonreactive NST result is a sleep cycle in a
normal fetus that is longer than average
31Hale T., M.D., Resident Physician

32. Hale T., M.D., Resident Physician 32

33. • Multiple parameters of wellbeing are better
predictors of outcome
• Five variables , with a total possible score of
10
• Some other propose inclusion of placental
grading with total possible score of 12
6. Biophysical Profile (BPP)
grading with total possible score of 12
• Several other investigators proposed a
modified BPP that usually includes heart rate
monitoring and amniotic fluid evaluation
33Hale T., M.D., Resident Physician

34. • Doing biophysical profile
testing = in utero physicaltesting = in utero physical
examination of the fetus!
Hale T., M.D., Resident Physician 34

35. • Causes of death in reasuring BPP
– Fetomaternal hemorrhage
– Cord accidents
– Abruptioplacenta– Abruptioplacenta
Hale T., M.D., Resident Physician 35

36. Hale T., M.D., Resident Physician 36

37. Hale T., M.D., Resident Physician 37

38. 1. Fetal Breathing Movements (FBMs)
• Normal
• Intermittent multiple breaths/ in 30 minutes/that
lasts more than 30 seconds
• Hiccups count
• Abnormal• Abnormal
• Continuous breathing without cessation
• Completely absent breathing or no
sustained episode of > 30 seconds
38Hale T., M.D., Resident Physician

39. • Fetal Breathing Movements
• This fetal behavior is the one most easily
suppressed by hypoxemia, but it is also the
most episodic in normal fetuses
• Within 30 minutes of observation FBM
incidence ranges 0-98%, average 30%incidence ranges 0-98%, average 30%
• Normal fetus can have a period of apnea of
108 minute
• Controversies over effect of certain agents on
FBM
• Low 5 minute APGARs & Fetal distress
more frequent when FBM absent
39Hale T., M.D., Resident Physician

40. • Not realiabily seen before 20 weeks by
real time ultrasound
• Before 20 weeks of gestation difficult to
distinguish FBM from generalized chestdistinguish FBM from generalized chest
movement
Hale T., M.D., Resident Physician 40

41. Factors affectiong FBM movement
Increased Decreased No change Controversial
1. Maternal
glucose
administra
tion
1. Nicotine
2. Labor
3. PROM
4. Chorioamn
1. Caffeine 1. Benzodiaz
epines
2. Demerol
3. Epiduraltion
2. Hypercapn
ia
3. Increasing
gestational
age
4. Chorioamn
ionitis
5. Amniocent
esis
6. MgS04
tocolysis
3. Epidural
4. Oxytocine
Hale T., M.D., Resident Physician 41

42. • Associations of FBM with Perinatal
Outcome
– Fetal distress in Labor
• FBM absent  60%• FBM absent  60%
• FBM present 30%
– Low 5 min APGAR Score (< 7)
• FBM absent 50%
• FBM present 4%
Hale T., M.D., Resident Physician 42

43. 2. Nonstress test (NST)
• Normal
• Moderate variability
• Accelerations associated with maternal palpation
• FMs (accelerations graded for gestation) on 20-
minute NST)
• ≥2 episodes of acceleration of 15 bpm and of• ≥2 episodes of acceleration of 15 bpm and of
≥ 15 s associated with fetal movement in 20
min
• Abnormal
• FM and accelerations not coupled
• Insufficient accelerations, absent accelerations, or
decelerative trace
• Minimal or absent variability 43Hale T., M.D., Resident Physician

44. • NST
– Contraction stress test, a test of
uteroplacental function
– Fetal heart rate acceleration in response– Fetal heart rate acceleration in response
to fetal movement as a sign of fetal health
– May show
• Unsuspected spontaneous late decelarations
• Variable decelerations
44Hale T., M.D., Resident Physician

45. • NST might be affected by
– Fetal sleep cycle
– Maternal smoking
– Maternal medications– Maternal medications
– Hypoxia
Hale T., M.D., Resident Physician 45

46. • In fetuses at or beyond 32 weeks, the
acceleration acme is 15 bpm or more
above the baseline rate, and the
acceleration lasts 15 seconds or longeracceleration lasts 15 seconds or longer
but less than 2 minutes
• Before 32 weeks, accelerations are
defined as having an acme that is 10
bpm or more above baseline for 10
seconds or longer
Hale T., M.D., Resident Physician 46

47. Tracing A:
Reactive NST
Hale T., M.D., Resident Physician 47
Tracing B:
Nonreactive
NST

48. FHR-R increases with GA...
Hale T., M.D., Resident Physician 48

49. • Abnormal nonstress test is not
always malignant!
• Nonstress tests that were nonreactive
for 90 minutes were almost invariably—for 90 minutes were almost invariably—
93 percent—associated with significant
perinatal pathology
Hale T., M.D., Resident Physician 49

50. • Terminal cardiotocogram includes:
– Baseline oscillation of less than 5 bpm
(Sinusoidal Pattern)
– Absent accelerations, and– Absent accelerations, and
– Late decelerations with spontaneous uterine
contractions
– Bradycardia
– Tachycarida
– Arrhythmia
Hale T., M.D., Resident Physician 50

51. • How should we proceed with fetal
bradycardia and tachycardia not in
labor?
• Can arrhythmias be treated in utero?
– Rx– Rx
• Digoxin ?
• Sotalol
• Flecainide
• Beta agonists
• Steroid or immunoglobulin adminstration
• Electrical pacemaker therapy
Hale T., M.D., Resident Physician 51

52. • NST frequency
– Daily
• For severe preeclampsia
– 2x weekly and addional testing compeleted for
maternal or fetal detoriorartion regardless of timematernal or fetal detoriorartion regardless of time
elapsed from the last test
• Postterm pregnancy
• DM
• IUGR
• Multifetal gestation
• Gestational hypertension
Hale T., M.D., Resident Physician 52

53. • Causes of death of a fetus within 1 week
of normal NST
– Meconium aspiration
– Intrauterine infection– Intrauterine infection
– Abnormal cord position and cord accidents
– Placental abruption
Hale T., M.D., Resident Physician 53

54. 3. Body or Limb Movements
• Normal
• At least 3 discrete movements / in 30 minutes
• Includes
• Fine motor movements,
• Rolling movements,• Rolling movements,
• But not rapid eye movements or
mouthing movements
• Abnormal
• Two or fewer body or limb movements /in a 30-
min observation period
54Hale T., M.D., Resident Physician

55. • Movements include
– Swallowing,
– Facial expressions,
– Sucking,
– Yawning,– Yawning,
– Large kicks,
– Small kicks, and
– Rolling motions
• When a fetus does not move for a period of
30 minutes, extended testing is required
55Hale T., M.D., Resident Physician

56. • Factors that cann affect GBM
– Caffein  Not much effect
– Maternal glucose  controversial
– Cocaine intoxication  Increases GBM– Cocaine intoxication  Increases GBM
Hale T., M.D., Resident Physician 56

57. 4. Fetal Tone or Posture
• Normal
• Demonstration of active extension with rapid
return to flexion of fetal limbs and brisk
repositioning or trunk rotation
• Opening and closing of hand or mouth,• Opening and closing of hand or mouth,
kicking,
• Abnormal
• Low-velocity movement only
• Incomplete flexion, flaccid extremity
positions, abnormal fetal posture
57Hale T., M.D., Resident Physician

58. • Fetal Movement and Tone
• Absent tone
• Strongly correlates with fetal acidosis
• Associated with the highest perinatal death rate
• Associated with a NR-NST, absent FB, and absent
FMFM
• A NR-NST and absent FT were the most
efficient pair for prediction of poor outcome
• 158 cases
• 9 FT absent
• 7 bad outcome (NST was absent)
• 2 good outcome (NST was present)
58Hale T., M.D., Resident Physician

59. 5. Amniotic Fluid Evaluation
• Normal
• At least one pocket larger than 2 cm with no
umbilical cord
• AFI of greater than 5 cms
• Abnormal• Abnormal
• No cord-free pocket greater than 2 cm or
multiple definite elements of subjectively reduced
amniotic fluid volume
59Hale T., M.D., Resident Physician

60. • Amniotic Fluid Volume
• Oligohydraminos (anatomically normal fetus
or no know known risk factors)
• Redistribution of fetal blood flow away from the
kidneys and lungs
• a reflection of uteroplacental insufficiency
• Why is oligohydraminos associated with• Why is oligohydraminos associated with
perinatal morbidity?
• Reflects an underlying uteroplacental insufficiency
• Risk factor for cord compression
60Hale T., M.D., Resident Physician

61. • Amniotic Fluid Volume
• Diagnosis of Oligohydramnios
• AFI Vs DVP
• With AFI
• More frequent Dx of oligohydraminos
• Labor induction was used more frequently
• Higher rate of cesarean deliveries for lack• Higher rate of cesarean deliveries for lack
of assurance of fetal well-being
• There were no differences in:
• Apgar scores,
• Umbilical artery pH (<7.1), or
• Non-reassuring FHR tracings
DVP preferred by most authors
Same outcome with less intervention 61Hale T., M.D., Resident Physician

62. • In doing SDVP we found
oligohydramnios or we suspect
a subjectively diminished
amniotic fluid. Should we do
a subjectively diminished
amniotic fluid. Should we do
AFI to prove that?
Hale T., M.D., Resident Physician 62

63. • Answer
– No!
– SDVP is superior to AFI for same outcome is
achieved with less intervention in usingachieved with less intervention in using
SDVP.
– The only part missing is which one predicts
risk of fetal death.
Hale T., M.D., Resident Physician 63

64. • Systematic Application of Biophysical Profile Scoring
• 10/10, 8/8, 8/10 (AFV normal)
• No evidence of fetal asphyxia
• PNM: Less than 1/1000
• Management
• No acute intervention on fetal basis; serial
testing indicated by disorder-specific protocols
• 8/10-oligo• 8/10-oligo
• Chronic fetal compromise likely
• PNM: 89/1000
• Management
• For absolute oligohydramnios, prove normal
urinary tract, disprove undiagnosed ROM,
consider antenatal steroids, and then deliver
64Hale T., M.D., Resident Physician

65. • 6/10 (AFV normal)
• Interpretation: Equivocal test; fetal asphyxia is not
excluded
• PNM: Depends on progression (61/1000 on
average)
• Management: Repeat testing immediately, before
assigning final valueassigning final value
• If score is 6/10, then 10/10, in two continuous
30-minute periods, manage as 10/10
• For persistent 6/10, deliver the mature fetus,
repeat within 24 hr in the immature fetus,
then deliver if less than 6/10
65Hale T., M.D., Resident Physician

66. • 4/10
• Interpretation: Acute fetal asphyxia likely, If AFV-
oligo, acute on chronic asphyxia very likely
• PNM: 91/1000
• Management: Deliver by obstetrically
appropriate method, with continuous
monitoringmonitoring
66Hale T., M.D., Resident Physician

67. • 2/10
• Interpretation: Acute fetal asphyxia likely with
chronic decompensation
• PNM: 125/1000
• Management: Deliver for fetal indications
(frequently requires cesarean section)
• 0/10
• Interpretation: Severe, acute asphyxia virtually
certain
• PNM: 600/1000
• Management: If fetal status is viable, deliver
immediately by cesarean section
67Hale T., M.D., Resident Physician

68. • Vibroacoustic Stimulation
• Stimulating the fetus with a noxious vibration
and noise is effective in
• Producing a state change,
• Fetal startle movements, and
• Increased FHR variability, thereby• Increased FHR variability, thereby
shortening the time it takes to demonstrate
fetal well-being  acoustic stimulation
nonstress test
• A positive response is defined as the rapid
appearance of a qualifying acceleration
following stimulation
68Hale T., M.D., Resident Physician

69. • VAS cont’d
– Decrease incidence of nonreactive NST to 6-
9%
– Nonreactive NST after VAS  worse– Nonreactive NST after VAS  worse
outcome than nonreactive without
stimulation
– No long term effect on the fetal ears
Hale T., M.D., Resident Physician 69

70. • BPP Vs mean arterial PH
– BPP 8  pH = 7.28
– BPP 4  pH = 6.99
Hale T., M.D., Resident Physician 70

71. • False postive rates of BPP scores
– 0  20%
– 6  75%
Hale T., M.D., Resident Physician 71

72. • Contraction Stress Test AND Oxytocine
Challenge Test
• Provocative tests using FHR responses to
uterine activity to evaluate fetal health
• Contraction Stress Test
• Spontanneously occuring contractions or through
nipple stimulation
• Oxytocine Challenge Test
• Inducing uterine activity through intravenous
Oxytocine
72Hale T., M.D., Resident Physician

73. • Contraction Stress Test AND Oxytocine
Challenge Test
• Positive/nonreactive
• 3 contractions followed by 3 late decelartations
• Variable decelerations• Variable decelerations
• Usually show oligohydraminos or cord entrapment
73Hale T., M.D., Resident Physician

74. Hale T., M.D., Resident Physician 74

75. Tracing A:
Reactive and
Negative CST
Hale T., M.D., Resident Physician 75
Tracing B:
Nonreacitve
and Negative
CST

76. • Contraction Stress Test AND Oxytocine
Challenge Test
• Disadvantage
1. Not indicated in
 Preterm PROM, multiple gestation, cervical
incompetence, PP, previous uterine surgery and previousincompetence, PP, previous uterine surgery and previous
CS delivery
2. Time consuming and cumbersome
3. Low positive predictive value
76Hale T., M.D., Resident Physician

77. • Doppler Ultrasound
• Helps to assess placental status
• Good predictor of sudden fetal deterioration
in IUGR
• Important to determine fetal reserve in IUGR• Important to determine fetal reserve in IUGR
• Categorizes risk wise for BPP monitoring
• Cannot be used alone and is not a primary
tool of antenatal fetal surveillance for eirther
high risk or low risk pregnancies
77Hale T., M.D., Resident Physician

78. • Umblical artery dopler
• Reduction→loss→reversal of diastolic flow
 Correlate with fetal outcome in deteriorating order
• In cases of worsening umblical artery dopler
outcomesoutcomes
 Asses fetal circulation directly
• Arterial Circulation: Middle cerebral
artery [MCA] and
• Systemic Circultion: Precordial veins
wave forms
78Hale T., M.D., Resident Physician

79. • Umblical Artery
• Arise from the common iliac arteries and
represent the dominant outflow of the distal
aortic circulation
• Because there are no somatic branches after
their origin, the umbilical arteries purelytheir origin, the umbilical arteries purely
mirror the downstream resistance of the
placental circulation
• Resistance falls as pregnancy advances
• Increased resistance in pathologic conditions
79Hale T., M.D., Resident Physician

80. • Umbilical artery Doppler [Measurement]
• Obtain a free loop of cord in the midsection
• Do when the fetus is at rest
80Hale T., M.D., Resident Physician

81. • Umbilical artery Doppler [Significance]
• Fetal growth restriction
• Placental insufficiency due to preeclampsia or
maternal conditions
• Absent flow and reversed flow represent
progressively ominous findings necessitating
close monitoring or consideration of delivery
based on the gestational agebased on the gestational age
• If you have umblical artery dopler
abnormalities
• Make prepartions for delivery
• Antenatal steroids
• Thorough fetal anatomic scan
• Invasive procedures for karyotype (like
amniocentesis)
81Hale T., M.D., Resident Physician

82. • If you have umbilical artery Doppler
abnormalities
• After 34 weeks -> Delivery
• Before 34 weeks ->Needs individualization
82Hale T., M.D., Resident Physician

83. • REDV
• Administer antenatal steroids before delivery
If
• BPP is normal
• Amniotic fluid is adequate,
• There are no decelerations identified on
the NST, and venous Doppler
measurements are normal,
83Hale T., M.D., Resident Physician

84. • Who?
• Maternal medical complications
• Diabetes mellitus,
• Chronic hypertension,
7. Practical Aspects of Fetal Testing
• Chronic hypertension,
• Systemic lupus erythematosis
• Thrombophilia
• Obesity
• Other sources of placental impairment
84Hale T., M.D., Resident Physician

85. – Pregnancy complications
• Multiple gestation,
• Oligohydramnios
– Maternal bad habits
• Cigarette smoking,
• Cocaine and
• Other toxic substance abuse, and• Other toxic substance abuse, and
– Fetal conditions
• Rh isoimmunization,
• Fetal growth restriction
• When?
– 32 to 34 weeks
– 24 weeks
85Hale T., M.D., Resident Physician

86. •Should we institute
antepartum fetal
surveillance for allsurveillance for all
obstetric patients?
Hale T., M.D., Resident Physician 86

87. • Answer
– Yes!
– Patients judged to be at high risk based on
known medical factors but whose fetusesknown medical factors but whose fetuses
demonstrated normal antepartum fetal
evaluation had a lower PMR than did
patients considered at low risk, whose
fetuses had abnormal antepartum testing
results.
Hale T., M.D., Resident Physician 87

88. Conditon-Specific Testing Strategies
Hale T., M.D., Resident Physician 88

89. BPP in Specific Maternal Conditions
• Labor
– FM and FB are the two components most
commonly altered during labor
– BPP is not relaible predictive test for acid-– BPP is not relaible predictive test for acid-
base status during the intrapartum state
– Todate BPP is not recommended during
labor
Hale T., M.D., Resident Physician 89

90. • Postdate pregnancy
– Twice weekly
– Normal BPP
• Low 1st min APGAR  1.9%• Low 1st min APGAR  1.9%
• CS risk  3.3%
• Neonatal morbidity  infrequent
– Abnormal BPP
• Low 1st min APGAR  12.5%
• CS risk  22%
• Neonatal morbidity  19%
Hale T., M.D., Resident Physician 90

91. • PROM
– Presence of Normal BPP is strongly
associated with the absence of fetal
infectioninfection
– Not known if the converse is true!
– Risk of infection
• BPP < 7
– 93.7%
• BPP > 8
– 2.7%
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92. • Is daily NST or BPP
recommended to predict
infection in preterm PROM?infection in preterm PROM?
Hale T., M.D., Resident Physician 92

93. • Answer
– Twice weekly BPP is sufficient in preterm
PROM!
– Daily BPP only increases cost and consume– Daily BPP only increases cost and consume
time without apparent benefit!
Hale T., M.D., Resident Physician 93

94. • IUGR
– Doppler velocimetry decreased perinatal
death of growth restricted fetuses by 38%.
– Use of BPP in IUGR is justifiable– Use of BPP in IUGR is justifiable
– In growth restriced fetuses which one does
occur earlier?
• Abnormal Doppler velocimetry Vs Abnomral
BPP?
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95. • Twin Gestations
– Secondary backup evaluation of NR-NST
– Sonography required for interval growth and
AFV throughout antenatal periodAFV throughout antenatal period
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96. • Diabetes Mellitus
– Best way to attain fetal wellbeing  by
achieving excellent maternal blood sugar
controlcontrol
– However BPP is predictive of fetal condition
in mothers with diabetic vasculopathy
– Amniotic fluid status should not be taken
into account!
– BPP has no preditive role for fetuses of
mothers without vascular disease
Hale T., M.D., Resident Physician 96

97. • MgS04 Tocolysis
– MgS04 affects FB and FHR-R causing a
decrease in BPP score
– No signnificant effect on FT, FM or AFV– No signnificant effect on FT, FM or AFV
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98. • Detecting congenital anomalies
– Dependant on the skill of the sonographer
– Proven record of difficulty
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99. • Cerebral Palsy
– Normal last BPP  0.7 / 1000 live births
– Score of 6/10  13.2 / 1000 live births
– Score of 0/10  333 / 1000 live births– Score of 0/10  333 / 1000 live births
– The link in between last BPP and CP is
inverse, exponential, highly significant!
Hale T., M.D., Resident Physician 99

100. • Corticosteroid use
– Decreased BPP score in a third of fetuses
within 48 hours of corticosteroid use
– Within 24-48 hours of these resutls the BPP– Within 24-48 hours of these resutls the BPP
scores normalized in the fetuses whose
scores had dcreased by 4 points
– FB, FHR-R parameters most affected
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101. • History of stillbirth in previous pregnancy
– Recurrent still birth  3x
– Begin fetal testing at 32 weeks
Hale T., M.D., Resident Physician 101

102. • Impacts of Monitoring on Perinatal Mortality
and Long Term-outcomes
• Lower BPP scores have been associated with
higher perinatal mortality rates
• Use of Doppler associated with a reduction in
perinatal deaths and there were also fewerperinatal deaths and there were also fewer
inductions of labor
102Hale T., M.D., Resident Physician

103. 103Hale T., M.D., Resident Physician

104. Hale T., M.D., Resident Physician 104

105. • Important Notes
– Corticosteroid use
– Magnesium Sulfate tocolysis
– Cerebral palsy– Cerebral palsy
– History of stillbirth in previous pregnancy
– Detecting congenital anomalies
105Hale T., M.D., Resident Physician

106. • 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 outweight the potential
risks and the costs
8. Summary
risks and the costs
106Hale T., M.D., Resident Physician

107. • Summary cont'd
• Management based on multivariable fetal assessment,
with BPP scoring as a central element and the
liberal addition of Doppler assessment of placental
and fetal circulations, can help to prevent iatrogenic
prematurity and provide reassurance regarding fetal
well-beingwell-being
• The risks of neonatal injury resulting from prematurity
must be balanced against the risks of stillbirth and
permanent injury from ongoing pregnancy in the
setting of fetal compromise
• Multivariable testing, individualized management
based on maternal and fetal conditions
107Hale T., M.D., Resident Physician

108. References
1. Walsh, M, Glob. libr. women's med., (ISSN: 1756-
2228) 2008; DOI 10.3843/GLOWM.10209
2. Robert K. Creasy, 2014. Creasy and Resnik’s Maternal-
Fetal Medicine Principles and Practice, 7th edition.
Saunders, an imprint of Elsevier IncSaunders, an imprint of Elsevier Inc
3. Seven G. Gabbe, 2012. Normal and Problem
Pregnancies., 6th edition, Saunders, an imprint of
Elsevier Inc.
4. F. Gary Cunningham, 2014. Williams Obstetrics, 24th
edition, McGraw-Hill Education.
5. James R. Scott, 2008. Danforth’s Obstetrics and
Gynecology, 9th edition
Hale T., M.D., Resident Physician 108

109. Thank you for listening!
109Hale T., M.D., Resident Physician