1) Fetal surveillance techniques like biophysical profile (BPP) and Doppler velocimetry help assess fetal well-being and risk of complications like intrauterine growth restriction (IUGR). Abnormal results increase rates of operative delivery, neonatal morbidity and mortality. 2) The BPP evaluates fetal movement, tone, breathing and reactivity and is interpreted based on fetal sleep cycles. Abnormal results on Doppler of the umbilical artery, middle cerebral artery, ductus venosus or uterine arteries also indicate placental insufficiency risk. 3) Despite wide individual variation, regular antenatal testing aims to predict wellness rather than just illness and time deliveries for highest chances of good outcomes

1. ANTEPARTUM FETAL SURVEILLANCE
DR.D.ABISHARTHINI
1st YEAR
POSTGRADUATE

2. Y SURVEILANCE ?
PARAMETER OF COMPARISON IUGR NORMAL
CONTROLS
1..Incidence of operative delivery 22% 15.3%
2.Early neonatal morbidity 31.3% 4.6%
3.Early neonatal mortality 10.6% 0.1%
4.Late neonatal morbidity 14% insignificant

3. BIOPHYSICAL PROFILE
 Between 24 and 28 weeks’ gestation,
approximately 50% of NSTs are non reactive.
 In contrast, sonographically evaluated
variables are valid early in gestation and
account for 3 of the 5 components of BPP.
 The BPP may be used to verify fetal well
being if the NST is not reactive

4. PHYSIOLOGY
• Fetal movement and fetal tone develop
between 7.5 and 9 weeks menstrual age
• Fetal breathing movements are detectable
by at least, 17- 18 weeks gestation.
• Amniotic fluid may be reduced as early as
17.5 weeks by fetal acidosis.
• The components of BPP develop
sequentially. In order of appearance: tone,
movement, breathing, reactivity.

5. FETAL SLEEP WAKE CYCLE
• Fetal state (wake-sleep cycle) plays an
important role in interpretation of the BPP.
• In quiet sleep, the average time to obtain a
normal BPP is 26.3 minutes. (min 20 min to
max 75 min).
• The BPP is, therefore, continued for a
maximum of 30 minutes.

6. ACIDOSIS AND ABNORMAL BPP
• The NST and fetal breathing movements are
suppressed when the pH falls below 7.2.
• If the pH falls below 7.16, fetal tone and fetal
movements become abolished
• The presence of oligohydramnios with all of
the other variables of BPP being normal may
reflect chronic uteroplacental insufficiency.

8. FETAL CENTRAL NERVOUS SYSTEM CENTERS
 FETAL TONE - Cortex
 FETAL MOVEMENTS - Cortex nuclei
 FETAL BREATHING MOVEMENTS- Ventral
surface of 4th ventricle
 NST- Posterior hypothalamus, medulla

9. COMPONENTS

10. INTERPRETATION

11. MATERNAL AND FETAL CAUSES OF
STILLBIRTH WITHIN ONE WEEK OF A
NORMAL BIOPHYSICAL PROFILE SCORE
FETAL MATERNAL
Fetomaternal haemorrhage
Cord prolapse
Rupture of membranes
Vasa previa
Cord entanglement
Umblical artery thrombosis
Placental abruption
Diabetic ketoacidosis
Sickle cell crisis
Accidents
Acute poisoning/drug overdose
False normal test rate is 1/1000.

12. MODIFIED BIOPHYSICAL PROFILE
• NST and AFI
 False negative rate is 0.8/1000.(ACOG 2016)

13. DOPPLER VELOCIMETRY
Allows assessment of placental status and,
therefore, helps to place other testing results
in context as well as helping to determine the
relative risk of sudden fetal deterioration

14. V

15. DOPPLER ULTRASOUND VELOCIMETRY
• Arterial doppler wave form is helpful to assess
downstream vascular resistance .
• From these values, S/D ratio,
pulsatility index(PI=(S-D)/M),
resistance index(RI=(S-D)/S)
• In normal pregnancy, the S/D ratio, PI and RI
decreases as GA advances
• Higher values greater than 2 SDs above
gestational age mean indicates reduced diastolic
velocities and increased placental vascular
resistance. These features point towrd adverse
pregnancy outcome

16. UTERINE ARTERY DOPPLER
• At the start of pregnancy, the uterine signal pattern
shows high pulsatility with high systolic and low
diastolic flow velocities in addition to an early diastolic
(postsystolic) notch.
• This notch represents a pulse wave reflection due to
an increased peripheral vascular resistance and is
the spectral counterpart of incomplete trophoblast
invasion
.
• Beyond this period, the diastolic notch gradually
disappeared and is not seen after 24 weeks.

17. ABNORMAL UTERINE ARTERY DOPPLER
 Persistence of the diastolic notch (bilateral
notch or unilateral notch on placental side)
 High vascular resistance (increased indices)
 RI or PI >95th percentile
 Difference between right and left uterine
artery S/D ratio >1.0
 Uterine artery S/D >2.6 after 22-24 weeks
scan

19. UMBILICAL ARTERY DOPPLER VELOCIMETRY
 S/D ratio – most commonly used index
- abnormal if >95th percentile for GA
- Absent or reversed flow signify increased
impedance to UA blood flow.
- Poorly vascularized placental villi(70%)

20. NORMAL UMBILICAL ARTERY WAVEFORMS
 The absence of diastolic flow at 10 weeks’
gestation is a normal finding.
12 wks -AEDV
12-14 WKS
DIASTOLIC
FLOW
DEVELOPS
>14 WKS
EDV
PROGRESSES
GRADUAL DECREASE IN PI & RI VALUES

23. ABSENT END DIASTOLIC VOLUME
• Will progress to REDV over time
• 80-100% are delivered by CS ;
 rates of cs 6-45%(RCOG)
• Perinatal mortality in AEDF: 9%
AEDF is associated with fetal demise within 7
-21 DAYS

25. REVERSE END DIASTOLIC VOLUME
• Delivery as soon as possible .CS rates 45%
• Associated with highest frequency of fetal
compromise, neonatal complications,
perinatal morbidity and mortalitY
- Perinatal mortality REDF : 39%
- REDF is associated with fetal demise within
1-7 days
- Addition ofan abnormal venous doppler –
(mortality rate 41%)

26. RATES OF EMERGENCY CS SECTION(RCOG)
UMBLICAL ARTERY
DOPPLER ABNORMALITY
Placentalinsufficiency RATESOF CS SECTION
Normal
umblical artery
flow
>50% 6-9%
Increased PI &
RI values ,but
end diastolic
flow present
>70% 17-32%
Absent
/reversed end
diastolic flow
>90% 6-45%

27. MIDDLE CEREBRAL ARTERY DOPPLER
• Unlike the uterine and umbilical artery
vascular beds which constantly change with
advancing gestational age, the MCA vascular
bed resistance is almost constant throughout
pregnancy.
• RI = 0.75-0.85V

28. ABNORMAL MCA
 BRAIN SPARING EFFECT is reflected in the
MCA as increased diastolic flow with reduced
PI.

29. CEREBRO PLACENTAL RATIO
• In normal fetus, the placental vascular
resistance decreases as pregnancy
advances, whereas the MCA resistance is
almost constant
• PI - MCA/ PI UMB A >1
• If < 1, indicates fetal hypoxia

30. • In growth retarded fetus the disappearance of
brain sparing or presence of reversed MCA flow
is a critical event for the fetus and precedes
fetal deatH
• MCA response to fetal hypoxia is instant.
• High systole in MCA – Fetal anemia
• High diastole in MCA – brain sparing effect in
fetal hypoxia

31. DUCTUS VENOSUS DOPPLER STUDY
 Ductus venosus Doppler has moderate
predictive value for acidaemia and adverse
outcome.
 Ductus venosus Doppler should be used for
surveillance in the preterm SGA fetus with
abnormal umbilical artery Doppler and
used to time delivery(RCOG )
 An increased PI and retrogradde ‘a’ wave
reflects the onset of overt cardiac
compromise

37.  Role of magnesium sulphate ?

38. CONCLUSION
 Despite wide ranges,precision of any method
is limited
 Wide range of fetal normal biological
variations make interpretation and decsion
making challenging.
 Focus to use antenatal testing to forecast
antenatal wellness rather illness

40. REFERENCES
 Williams obstetrics
 Mudhaliar clinical obstetrics
 Dc Dutta textbook of obstetrics
 RCOG greentop guidelines 31.