This document summarizes antepartum fetal surveillance and aneuploidy screening. It discusses: 1) The importance and benefits of antepartum fetal surveillance in predicting risks like perinatal death and detecting conditions like fetal growth restriction. 2) The various methods used in aneuploidy screening including ultrasound measurements, maternal serum markers, cell-free DNA testing, and invasive diagnostic tests. 3) The guidelines and best practices for aneuploidy screening including integrating first and second trimester screens and contingent screening models based on risk levels.

1. Dr. SHARANYA SAHUKAR
ANTEPARTUM FETAL
SURVEILLANCE
MODERATOR:
Dr. NAGARATHNAMMA
Professor and Unit chief,
Department of OBG,
RRMCH, Bangalore.

2. WHY SHOULD WE DO IT?
• Extrinsic perinatal pathology accounts for 50% of deaths in term
infants and nearly two thirds in postterm infants.
• Nearly two thirds of the stillbirths are attributed to chronic process
such as uteroplacental insufficiency which could have been detected
during antepartum fetal surveillance.
• FGR,LBW is responsible for 0.6 million deaths and 24.6 million
disability attributed life in years in babies below 5 years in India.

3. • A decade of experience from 1974 to 1983 with contraction stress test
followed by NST was evaluated.
• The perinatal mortality rate was found to be 24.4 per 1000 in non tested
population versus 11.8 per 1000 in population who had undergone
antepartum surveillance.
• The stillbirth rate was also double( 11.1 per 1000) in the non tested group.

4. WHAT IT PREDICTS?
• Risk of perinatal death.
• Non reassuring fetal state.
• Preterm delivery.
• Congenital abnormalities.
• Fetal growth restriction.
• Need for fetal therapy.

5. MANAGEMENT IMPLICATIONS
• Prediction and prevention of preterm birth.
• Fitness for conservative management.
• Requirement of medications.
• Need for delivery.
• To decide upon route of delivery.
• Need for accelerating 2nd stage of labour.
• Neonatal need for ICU.

6. HOW SHOULD IT BE
PERFORMED?
• Preconception counselling.
• High risk categorisation.
• Antepartum fetal surveillance.
• Estimation of gestational age.
• Aneuploidy screening.
• Invasive prenatal testing.
• Detection of congenital anomalies.
• Fetal growth monitoring.
• Monitoring fetal wellbeing.

7. PRECONCEPTION CARE
• Preconception is the vital time to assess
and identify various risks that could lead to
adverse maternal and fetal outcomes.
• Preconception care identifies social
,behavioural,environmental and biomedical
risks to future pregnancy outcome and
reducing these risks through appropriate
intervention.

8. • Globally, unplanned pregnancy, maternal
age, undernutrition, iron deficiency anemia,
vaccine preventable diseases, sexually
transmitted diseases, epilepsy,smoking and
alcohol use are the main causes for poor
pregnancy outcome.
• An intense healthcare approach is desirable
to reduce the adverse pregnancy outcomes.

10. PRENATAL EVALUATION
Parameters
General
history
Maternal age,BMI, socioeconomic
status,nutrition.
Medical
history
Chronic disorders.
Past history Seizure disorder, psychiatric disorder.
Obstetric
history
Previous pregnancy, contraception.
Family
history
Genetic diseases.
Personal
history
Substance abuse.

11. GENERAL HISTORY
Age Spontaneous preterm, FGR related
to maternal disease,aneuploidy.
Low socioeconomic status Risk of perinatal mortality, preterm
birth and low birth weight.
Poor maternal nutrition Preterm delivery, FGR, stillbirth.
Overweight/ obesity Neural tube defects,
macrosomia,preterm
delivery,stillbirth,complications due to
diabetes, hypertension and
thromboembolic disorders in mother.
Underweight Preterm birth,low birth weight, birth
defects like gastroschisis.

12. SUBSTANCE ABUSE,
PSYCHOSOCIAL ISSUES
Substance Fetal outcomes
Tobacco
(smoking)
Placental dysfunction- preterm labour,
abruption,FGR, stillbirth
Alcohol Low birth weight,late fetal loss or stillbirth
,prematurity,fetal alcohol spectrum disorder,
sudden infant death.
Opioids Prematurity,low birth weight.
•Counselling regarding untreated illness, risk or relapse
during pregnancy, risk to fetus from teratogenecity of
antipsychotic drugs.

13. RADIATION EXPOSURE
• Human embryo and fetus are sensitive to
ionising radiation.
• Women who work with radiation should wear
a dosimeter to monitor the radiation exposure
levels.
• Women who are exposed to radioactive
iodine should plan pregnancy after an interval
of 6 months.

14. INFECTIONS- PRECONCEPTION
INTERVENTIONS
Intervention Proven benefit
Hepatitis B vaccination Reduces transmission to
infant.
HIV screening and
treatment
Reduces the risk of
vertical transmission.
Screening and treatment
of sexually transmitted
diseases.
Reduces possible risk of
fetal death,
physical,developmental
disabilities.
Rubella vaccination Protects against
congenital rubella
syndrome.

15. AIM OF ANTENATAL FETAL
SURVEILLANCE
• Ascertain fetal well-being.
• The main aim in high risk pregnancies is to
identify malformed fetuses and recognise
those fetuses which are at risk for
asphyxia so as to take timely action.
• Action may be in the form of further
specialised tests, interventions, referral or
immediate delivery.

16. FOR ALL? WITH ALL?
• Monitoring is necessary for all pregnancies
but nature and frequency varies for low risk
and high risk pregnancy.
• Serial antepartum surveillance using one or
more fetal assessment technqiues is the
standard of care for high risk pregnancies.

17. GESTATIONAL AGE
• Gestational age is estimated by
• Urine pregnancy test Positivity time.
• LMP.
• Clinical symptoms and examination.
• Ultrasonography.
• Quickening.
• Fetal heart rate.

18. IMPORTANCE OF GESTATIONAL
AGE
• Assessment of fetal well being.
• Timing and interpretation of various
investigations.
• Timing of invasive procedures.
• Assess the fetal growth.
• Timing the delivery of the fetus.

19. GESTATIONAL AGE ASSESSMENT
• Clinically most pregnancies are dated by
LMP,which is the single most reliable clinical
estimator of gestational age.
• Naegele’s rule is based on regular cycles.
• If LMP is unreliable ,dating by early
ultrasound examination at 8-14 weeks based
on Crown Rump Length (CRL) is the most
reliable .

21. • Once CRL exceeds 84 mm, HC should be
used for dating.
• In cases of unreliable LMP and no first
trimester scan, HC with or without FL can
be used for dating the pregnancy in mid
trimester.

22. CLINICAL ASSESSMENT- FUNDAL
HEIGHT

23. Excellent dates •Women with proper information
on LMP, no recent use of OCP,
uterine size correlating with
gestational age, ultrasound
done between 16 and 24 weeks
and corrects with gestational
age as per LMP.
Good dates •Women with adequate clinical
information and one confirming
ultrasound after 24 weeks.
•Women with inadequate clinical
information and 2 or more
ultrasound showing adequate
growth and similar EDD.
Bad dates •Any clinical situation other than
above.

24. ANEUPLOIDY SCREENING
• Aneuploidy often results in a non viable pregnancy or
offspring that may not survive after birth.
• In case of a surviving newborn, congenital birth
defects, failure to thrive, functional abnormalities,
intellectual disability, infertility and shortened life
span.
• Methods used for screening are
• Ultrasound.
• Serum markers.
• Invasive methods.

25. • Main goal is to provide accurate information
that will facilitate the delivery of optimised
antenatal care, with the best possible
outcome for both the mother and the fetus.
• ACOG and ISUOG recommends that all
pregnant women should be offered
aneuploidy screening or diagnostic testing
early in pregnancy.

26. • FTS- NT+Beta hCG+PAPP-A
• FTS+NB+DV+TR
• NT+NB+DV+TR
• Enhanced FTS- PAPP-A,free hCG,AFP,PlGF
• NIPT
Ist trimester
• Triple screening
• Quadruple screening
• Penta screen
• Target scan
• NIPT
II ND
trimester
• Integrated screening
• Serum integrated screening
• Sequential screening
• -stepwise screening
• -contingent screening
Combined
Ist and IInd
trimester

28. FIRST TRIMESTER SCREENING
• Maternal age with Nuchal translucency, serum
PAPPA –A and Free Beta hCG are combined into a
single test.
• Performed between 11 and 13+ 6 weeks
corresponding to gestational age with a CRL of 45
mm to 84 mm.
• Ultrasound to confirm viability, establish gestational
age, number of fetus and in presence of multiple
pregnancy assess chorionicity and amnionicity done
prior to FTS

29. FALSE POSITIVE IN
BIOCHEMICAL SCREENING
PAPP-A Beta hCG
Type I DM decrease unchanged
IVF pregnancy 9% higher 10 % higher
Obesity increase increase

30. NUCHAL TRANSLUCENCY
• Enlarged NT is defined as 3 mm or more or above 99th percentile for the CRL
and is independently associated with fetal aneuploidy and structural
abnormalities.
• Risk of adverse pregnancy outcome is proportional to the degree of NT
enlargement.
• NT is increased with fetus with
• chromosomal abnormalities
• congenital heart diseases.
• genetic syndromes.
• other structural abnormalities.

31. • Based on the risk calculated women is categorised into T21 screen
positive ( <1:250) and screen negative (>1:250).
• For T13,18 1:100 is taken as a cut off.

32. OTHER PARAMETERS SEEN IN
FIRST TRIMESTER SCREENING
• Nasal bone- not visible in 65% of T21 fetus, 2
% of chromosomally normal fetus.

33. DUCTUS VENOSUS FLOW
• Section taken in Midsagittal view with fetal thorax and abdomen occupying
the whole screen with an angle of insonation < 30 degree.
• In normal DV, only forward flow is seen – a wave is present.
• Abnormal DV- Reversed a wave throughout the waveform.
• Abnormal ductal flow is associated with chromosomal defects, cardiac
abnormalities , adverse pregnancy outcome.
• Observed in 80% of T21 and in 5% of chromosomally normal fetus.

34. TRICUSPID FLOW
• Section – 4 chamber view of the heart with fetal thorax occupying the
whole screen.
• Position of the heart can be apical or basal.
• Tricuspid regurgitation is diagnosed when the regurgitant jet must be
atleast half of systole with a velocity over 60to 80 cm/second.
• Tricuspid regurgitation increased the detection rate of FTS from 91 % to
96%.
• Seen in 55 % of T21 and 1.1% of normal fetus.

36. SECOND TRIMESTER - TRIPLE
SCREENING
• Triple marker screen measures serum hCG, AFP and
unconjugated estriol to determine risk estimate.
• In down syndrome, hCG is elevated and AFP and
unconjugated estriol are lower.
• Cut off of < 1 in 200 is taken as screen positive.
• DR is 69%, FP is 5%.

37. QUADRUPLE SCREEN
• Can be performed from 15 weeks to 22 +6 weeks.
• Best time to perform is from 16 weeks to 18 weeks with BPD measuring
34 mm- 52 mm.
• Also screens for open fetal defects.
• Involves measurement of hCG,AFP,dimeric inhibin A, unconjugated
estriol in combination with maternal factors such as age, weight, race,
presence of diabetes to calculate the risk.

38. • DR is 81-85%, FP is 7-8.3%

39. SCREENING METHODS
• Various screening methods are
• Integrated screening.
• Serum integrated screening.
• Stepwise sequential screening.
• Contingent screening.

41. STEPWISE SEQUENTIAL
SCREENING
Stepwise
sequential
screening
High risk
Cell free fetal
DNA
Diagnostic testing
Low risk Quadruple screen

42. CONTINGENT SCREENING
• This model classifies aneuploidy risk as high, intermediate and low on the
basis of FTS.
• Women at high risk are offered cell free fetal DNA or diagnostic testing.
• For low risk (>1:1000), no further testing is done.
• For intermediate risk (1:251-1:1000), second trimester screening is
offered.
• In this model high risk (<1:250) patients are identified and diagnostic
testing offered.

43. EARLY TRIMESTER- ANOMALY SCAN
• Advanced maternal age.
• Previous birth of malformed fetus.
• Family history of malformed fetus.
• Consanguinity.
• Exposure to drugs/radiations.
• Maternal diabetes mellitus.
• Bad obstetric history.
• Bleeding in early pregnancy.

44. DETECTION RATE OF
ANATOMICAL DEFECTS

45. SECOND TRIMESTER
(GENETIC SONOGRAM)
• Genetic sonogram is a targeted second trimester ultrasound examination of
major structural abnormality as well as minor markers of aneuploidy.
• Major abnormalities include
• Holoprosencephaly.
• Diaphragmatic hernia.
• Atrioventricular septal defect.
• Exomphalos.
• Megacystis.

46. MINOR ABNORMALITIES
• Increased nuchal skin fold.
• Shortened long bones.
• Pyelectasis.
• Absent/hypoplastic nasal bone.
• Hyperechoic bowel.
• Choroid plexus cyst.
• Ventriculomegaly.
• Echogenic intracardiac focus.

48. • Presence or absence of these markers either alone or in combination can
adjust patient’s aneuploidy risk obtained by second trimester screening.
• Markers such as widened pelvic angle and sandal gap deformity had fallen
out of favor.
• Newer sonographic findings such as aberrant right subclavian artery
(ARSA), prenasal thickness and FMF angle are gaining popularity.
• In isolation each marker carries low to moderate sensitivity and specificity.

49. • Presence of multiple markers improve detection rate.
• Likelihood ratio has been established for each individual marker and these
ratios multiplied by patient’s apriori risk gives the calculated new risk.

50. NEWER MARKERS
• Aberrant right subclavian artery (ARSA)- seen in 35% of fetus with Downs’
syndrome.
• Frontomaxillo facial angle is based on specific characteristic flat facial
profile seen in Downs’ syndrome.
• FMF angle increased the detection rate from 90% to 94 %.

52. CELL FREE DNA SCREENING
• ACOG(2015), guidance for Canada (Feb 2017),
International Society of Prenatal diagnosis recommends it
as screening tool for women at increased risk for
aneuploidy and not for low risk women.
 Can be performed from 9-10 weeks until delivery.
• Indications
• Intermediate group in contingent screening.
• Precise diagnosis.
• Advanced maternal age,precious pregnancy, ART
pregnancy.

53. • These DNA fragments are derived from maternal cells and from
apoptotic placental trophoblast cells.
• Ideal fetal fraction -10%.
• Results interpreted as either positive and negative
or > 99% as high risk and <1/10000 as low risk.
• Women with positive screen needs invasive testing to confirm the
diagnosis.Women with indeterminate or uninterpretable (a “no call “
test result) result should receive genetic counselling and offered
ultrasound evaluation and diagnostic testing.

55. INVASIVE PRENATAL DIAGNOSTIC
TESTING
• Diagnostic procedures include
amniocentesis, chorionic villi sampling and
rarely fetal blood sampling and fetal tissue
biopsy.
• Following introduction of cell free fetal DNA
there is 70% decline in CVS and 50% drop in
amniocentesis.

57. FETAL BLOOD SAMPLING AND
SKIN BIOPSY
• Cordocentesis or percutaneous blood sampling
is performed to diagnose single gene
disorders,fetal infection, fetal anemia, factor
V,VII,XIII deficiency.
• Sampling is done near the placental cord
insertion site.
• Due to modern techniques fetal tissue biopsy its
not routinely done.

58. ANEUPLOIDY SCREENING
DURING THE PANDEMIC
Women who wish to have aneuploidy screening but
have missed combined screening (11+2 -14+1
weeks)
-14+2 to17+6 a dating scan and quadruple
screening are offered.
-18+0 to 20 anomaly scan and quadruple test are
offered.
-20+1 to 23+0 perform anomaly scan only. The
anomaly scan is the screening test for trisomy 18 and
13 in this instance.

59. TRIALS
BUN
study
•Biochemistry,
ultrasound
and nuchal
translucency.
•Evaluated
performance
of 1st trimester
screening
using
biochemical
test and NT.
Multicentric
trial involving
13 prenatal
diagnostic
centres
evaluated
8500 patirnts
over 4 years.
Study
reported
a 85.2%
trisomy
21
detection
rate with
.4% false
positive
rate.

60. SURUSS – SERUM URINE &
ULTRASOUND SCREENING
STUDY
• A prospective study of 47,053 singleton pregnancy conducted in 25
maternity units.
• Serum and Urine samples collected between 9 and 13 weeks and again
between 14 and 20 weeks of pregnancy and stored.NT measurement was
taken.
Serum markers AFP,total Hcg,free beta
hcg,dimeric inhibin-
A,unconjugated estriol,
PAPP-A .
Urine markers Invasive trophoblast
antigen,beta core fragment,
total hcg, free beta hcg.
Ultrasound marker Nuchal translucency

61. • Most effective and safe screening method
• Overall- integrated test with DR 85% for T21.
• If NT not available- serum integrated test.
• The Quadruple test is best for women who first
attend antenatal care in the second trimester.
• For screening in first trimester- combined test.
Screening test False positive
FTS 4.3%
Integrated test 0.9%
Serum integrated test 2.7%
Quadruple test 6.2%
NT alone 15.2%

62. FASTER TRIAL- FIRST AND SECOND
TRIMESTER EVALUATION OF RISK
TRIAL,AJOG 2004
• Done to evaluate the performance of first and second trimester screening
methods for prenatal detection of aneuploidies other than Downs’
syndrome.
• Singleton pregnancies( 38167 completed 1st, 35,260 completed 2nd
trimester screening ) at 15 US centres.
2nd trimester quadruple screening is effective for detecting T18 and
triploidy.1st trimester combined screening is effective for all aneuploidies.
Total non Downs’
aneuploidies(78)
Trisom
y 18
(29)
Trisomy 13
(15)
Turner
syndrome(26)
Triploidy (8)

63. OSCAR TRIAL- ONE STOP CLINIC
FOR ASSESSMENT OF RISK FOR
T21 AT 11-14 WEEKS
• Evaluated T21 by combination of maternal age, fetal NT thickness and
maternal serum Beta hCG ,PAPP-A at 11-14 weeks .
• 15,030 singleton pregnancies were screened. Follow up of the outcome of
all pregnancies carried out.
• The detection to false positive rates for different risk cut offs were
calculated.
• The detection rate was 90% for a false positive rate of 5% for T21 by
OSCAR.

64. 2ND TRIMESTER TARGET SCAN
• It is offered from 18-22 weeks (ACOG).
• With current advances, 50% of major
anomalies are detected by ultrasound.
• Maternal obesity is associated with 20 %
reduction in anomaly detection rate.
• It is important to assess anomalies, decide on
termination of pregnancy, invasive
procedures and for planning neonatal care.

65. AIMS OF SECOND TRIMESTER
ULTRASOUND
• Assessment of gestational age if not done
in 1st trimester.
• Assessment of fetal biometry.
• Anatomical survey to rule out
malformations.
• Assessment of placental location and cord
insertion.
• Measurement of cervical length to assess
risk of preterm delivery.

68. FETAL ECHOCARDIOGRAPHY
• Nearly 8 of 1000 live births have some form of
congenital heart disease.
• Nearly half are not identifiable antenatally.
• Performed from 18-22 weeks.
• About one third of major heart disease can be
picked up by second trimester ultrasound.
• Detailed fetal echo is performed if any abnormality
in four chamber and outflow tract views are
present during routine target scan.

69. INDICATIONS FOR FETAL
ECHOCARDIOGRAPHY

70. 3D SCAN
• 3D scans aid in correct demonstration of median plane eg. Flat profile,
defects of fetal face, abnormal brain defects, abdominal wall
defects,defects of limbs.
• 3D surface mode with colour doppler clearly depicts blood vessels in
fetal brain and abdomen.
• Transparent mode aids in evaluation of foetal skeleton.
• Clinical advantage of 3D US for prenatal diagnosis is lacking (ACOG).

71. FETAL MRI
No biological risks are associated with fetal
MRI.
• Indications
• Congenital anomalies of brain,spine.
• Suspected masses in thorax,abdomen,
pelvis.
• Complications of monochorionic twins.
• Fetal surgery assessment.
• It provides additional information in some
cases,aids in predicting the prognosis in
CDH.

72. FETAL GROWTH MONITORING
• Screening and surveillance of fetal growth is
an essential part of good antenatal care.
• Methods available are
• Maternal weight gain.
• Symphysiofundal height.
• Uterine height.
• Abdominal girth.
• Ultrasonography- biometry.

73. WEIGHT GAIN IN PREGNANCY
Low weight gain Preterm labour,low birth
weight infants.
Excessive weight gain Pre-eclampsia,failed
induction,cesarean
delivery,macrosomia.

74. UTERINE SIZE- SYMPHYSIO FUNDAL
HEIGHT

75. SYMPHYSIOFUNDAL HEIGHT
(RCOG)
• SFH is checked during every antenatal visit
after 24 weeks not more frequently than 2
weeks for women with singleton pregnancy.
• If SFH is small or large for gestational age ,
ultrasound for growth and fetal well being is
done.
• Urgency depends on the additional clinical
findings.

76. GRAVIDOGRAM
• Gravidogram is a simple and inexpensive
screening tool useful in detection of
FGR.Both gravidogram and ultrasound,
when used together, have higher detection
rates.
• It is a graphic comparison between
changes in SFH, AG, maternal weight.

77. FETAL BIOMETRY
• The most common fetal biometric
parameters
• Biparietal diameter (BPD)
• Head circumference (HC)
• Abdominal circumference (AC)
• Femur diaphysis length (FL)
• These biometric measurements are used
to estimate fetal weight (EFW) using
various formulae.

79. ESTIMATED FETAL WEIGHT
• EFW can be calculated using AC and HC,AC,HC and FL.
Disadvantages
• Errors in single parameter measurement.
• Intra and interobserver variation about 10-15%
errors.
• The main parameter AC measurement can be
difficult due to technical factors.
• To minimise false-positive rates , the time interval between scans
should be 3 weeks to detect fetal growth disorders.
• Hadlock is the most commonly used method.

80. INDICATIONS FOR SERIAL USG
BIOMETRY

81. • Fetal growth is a dynamic process so
atleast 2 ultrasound scans 3 weeks apart
are required to assess fetal growth.
• FGR is associated with stillbirth,neonatal
death, perinatal morbidity, and delayed
complications such as cerebral palsy and
adult diseases.

82. CUSTOMISED GROWTH CHART
• Customised charts have reduced the
incidence of normally small fetus and doubled
detection of FGR from 20% to 50%.
• A computer generated growth chart should
be customised for each individual during
pregnancy.
• GROW (gestation related optimal weight)
customised charts plots SFH and EFW.
• RCOG recommends customised charts.

83. FETAL GROWTH LONGITUDINAL
STUDY- PART OF INTERGROWTH
21,2014
• Recruited 4607 low risk women with
adequate health and nutritional status
across 8 countries.
• Five ultrasound parameters- HC,
BPD,OFD,AC,FL were obtained every 5
weeks from 14 weeks to 42 weeks.
• Best fitting curves for 3rd,5th,10th ,50th,90th ,
95th and 97th centile curves for gestational
age representing international standards
were generated.

84. FETAL WELL BEING SURVEILLANCE
-EARLY PREGNANCY
• Placental markers are
• Uterine artery doppler.
• Biochemical markers
• PAPP-A
• Beta hCG
• MSAFP
• PlGF

85. FETAL WELL BEING-
SURVEILLANCE- BIOPHYSICAL
• Fetal movement count.
• Contraction stress test.
• Non stress test.
• Biophysical profile.
• Modified biophysical profile.
• Doppler.

86. WHEN TO INITIATE?
• Initiate antenatal fetal surveillance at 32 0/7
weeks or later for most at-risk patients
(ACOG).
• For pregnant woman with one or more high-
risk conditions (eg, chronic hypertension
with suspected fetal growth restriction),
initiating the surveillance depends on the
hospital’s ability to care for the preterm
neonates.
• In India, time varies between 28-32 weeks.

87. HOW REASSURING IS A NORMAL
ANTEPARTUM FETAL
SURVEILLANCE?
• In most cases , normal surveillance test is highly reassuring
because of its low false negative rates, defined as incidence of
stillbirth occuring within 1 week of a normal test result.
• However stillbirths due to acute changes in maternal- fetal
status cannot be predicted.
• There is a lack of high quality evidence from RCTs that
antepartum surveillance decreases the risk of fetal death.
.

88. • The test results must be interpreted with caution
if performed before 32 weeks of gestation.
• NST of a normal preterm fetus is nonreactive in
up to 50% of fetuses between 24 and 28 weeks
and 15% of fetuses between 28 and 32 weeks.
• As individual tests, NST and doppler provide
better results.

89. Specificity Greater than 90% for
almost all tests.
Sensitivity 69% - NST, 21% -
doppler.
NPV Greater than 85% for
almost all tests.
PPV 81%- NST, 42% - AFV
assessment.
oBecause of the high false-positive rates and low
positive predictive value, abnormal test results
(particularly at low gestational ages) are often followed
by another test to evaluate fetal status.

90. FREQUENCY
• If maternal medical condition is stable and
test results are reassuring, tests are repeated
at weekly intervals.
• In the presence of certain high-risk
conditions, some investigations have to be
performed more frequently.

91. SCREENING IN EARLY
PREGNANCY- BIOCHEMICAL
MARKERS
• Due to low sensitivity,specificity and low
predictive value these markers are not used for
predicting adverse outcomes.
Trimester Parameter Implication
Ist trimester Low PAPP-A or
hCG Placental related
diseases- FGR,
pre-eclampsia,
preterm birth, fetal
demise.
IInd trimester Elevated AFP,
hCG or inhibin-A
IIIrd trimester Low PlGF

92. UTERINE ARTERY DOPPLER
• Ut artery doppler has more of predictive value
for IUGR and PRE-ECLAMPSIA. 95th
percentile or more is taken as high
resistance.
• Mean uterine artery PI is always taken.
• Uterine artery PI may be affected by maternal
factors like ethnic origin, BMI and previous
PE.

93. RISK ASSESSMENT FOR PRE-ECLAMPSIA
AND IUGR
• If mean PI values are normal, the patient
can be informed that she most likely will
not develop preeclampsia or have an
IUGR fetus, as there is >99% negative
predictive value
• If mean PI is abnormal, patients are
followed with more frequent antenatal
visits and ultrasound for growth monitoring
as the test has got only 50-75% positive
predictive value.
• Abnormal doppler is associated with 3 to 4
fold increase in risk of stillbirth.

94. NORMAL UTERINE ARTERY WAVEFORMS

95. • RCOG recommends uterine artery doppler
at 20-24 weeks in high risk women.
• If doppler is abnormal at 20-24 weeks
serial ultrasound for fetal size and well
being is done with umbilical artery doppler
commencing at 26-28 weeks.

96. FETAL MOVEMENT
• Fetal movement is a sign of well being.
• A mother is able to perceive 70%-80% of all
fetal activity.
• By third trimester fetus spends 10% of its
time making gross fetal body movements with
approximately 30 movements /hr.
• Regardless of the risk status all women
should monitor fetal activity starting at 26
weeks.

97. PHYSIOLOGY OF FETAL
MOVEMENTS
• Distinct gross body movements can be seen
as early as 7th week.
• Mother perceives movements by 18-20
weeks (multigravida) or 20-22 weeks
(primigravida) which are felt as flutter or
vibration.
• Fetal movements follow circadian pattern
which are more in the late evenings.

98. • Fetal movements increase in force and
frequency till 32-34 weeks perceived as kick,
punch,roll or turn.
• There is a plateau by 34 weeks after which there
is a gradual decrease in perception.
• Variation in movements – 4 to 100 times/ hr with
an average of 31/hr.
• The average sleep cycle is 20-40 min, longest
cycle being 90 min.

99. FETAL MOVEMENT COUNTING
• ACOG recommends fetal movement counting in all women
starting at 26-32 weeks but NICE does not recommend.
• In a systemic review in Cochrane database higher compliance
was noted with Cardiff count to 10 and other outcomes were
the same in both methods.
Method CARDIFF COUNT TO 10 Daily fetal movement
count
Normal A count of 10 in 12 hrs. 3 counts each in 1hr
counted 3 times a day.
Caution Less than 10 movements in 12
hrs on 2 successive days (or)
no movement even after 12 hrs in
a single day.
If less than 10
movements in 12 hrs or
< 3 movements in each
hr.

100. FACTORS ASSOCIATED
WITH REDUCTION OF
FETAL MOVEMENTS
Actual reduction in fetal
movements
Reduction in maternal
perception
•Fetal hypoxia.
•SGA or FGR fetus.
•Oligohydramnios.
•Fetus with major anomalies-CNS
and musculoskeletal anomalies.
•Fetal anemia.
•Fetal infection.
•Maternal habits- smoking, alcohol.
•Iatrogenic-glucose ,steroids
,sedatives.
•Drugs- narcotics ,propranolol
,phenobarbitone.
•Fetal sleep (quiet)
•Obesity.
•Anteriorly located placenta.
•Polyhydramnios.
•Fetal position- fetus with the back
anterior.
•Maternal position- upright
postures.
•Attention on other activities for
prolonged periods.

101. CONTRACTION STRESS TEST
• Also known as oxytocin challenge test is based on the response of the FHR to
uterine contractions ,used particularly in utero-placental insufficiency.
• Mimics the stress of labour.
• Contraindications
• Premature rupture of membranes.
• Cervical incompetence.
• Multiple gestation.
• Polyhydramnios.
• Placenta previa.
• Previous uterine surgeries.

102. HYPOTHESIS
Contractions followed by Increased
myometrial pressure and amniotic fluid
pressure
Decreased blood flow and oxygen
exchange in intervillous spaces of
placental circulation.
Fetus with inadequate placental
reserve demonstrate late
decelerations in response to hypoxia.

103. • Uterine stimulation is not necessary if patient
is having spontaneous uterine contractions of
adequate frequency.
• If contractions are not adequate ,induction
with either nipple stimulation or intravenous
oxytocin should be initiated.

104. PERFORMANCE OF CST

105. INTERPRETATION
Negative No late or significant variable
decelerations
Positive Late decelerations after 50% or more
of contractions (even if contraction
frequency is less than 3 in 10
minutes).
Equivocal -suspicious Intermittent late decelerations or
significant variable decelerations
Equivocal FHR decelerations occur in the
presence of contractions more
frequent than every 2 minutes or
lasting longer than 90 seconds.
Unsatisfactory Fewer than 3 contractions in 10
minutes
A suspicious , equivocal test needs to be repeated after 24
hrs as most will become negative.

106. Arias- Practical Guide to High Risk Pregnancy and Delivery- 5th Edition.
Test result Outcome Perinatal death
Negative Good fetal outcome. Repeat
after a week.
Less than 1 per
1000 in 1 week.
Positive Increased risk of intrauterine
death, late decelerations in
labour, low 5 minute APGAR
score, FGR, meconium
stained amniotic fluid.
7%-15 %
•A negative test is highly predictive of good
outcome.
•Positive test is predictive of fetal hypoxia with FP
rate of 8% to 57%.
•FP may be due to misinterpretation of tracing,
supine hypotension, uterine hyperstimulation.

108. BIOPHYSICAL PROFILE
• BPP was first described by Manning and colleagues in 1980.
• It integrates ultrasound observations and NST, can be
performed from 28-32 weeks.
• It is non invasive, quick method of assessing fetal well being.
• Acute components
• Fetal breathing movements.
• Gross body movements.
• Fetal tone.
• Reactive fetal heart rate
• Chronic component - Amniotic fluid volume.

109. INDICATIONS FOR BPP
• Small for gestational age fetus.
• Pre-eclampsia/ chronic hypertension.
• Post date pregnancy.
• PPROM.
• Decreased fetal movements.
• Pre-pregnancy diabetes.
• Insulin requiring gestational diabetes.

110. PHYSIOLOGICAL BASIS FOR BPP
• Fetal BPP components are regulated and
controlled by specific centres in the fetal nervous
system.
• The centre that develops earliest (fetal tone- 8
weeks) is the least sensitive to hypoxia.Absent
fetal tone implies intense hypoxia to CNS.
• Centres regulating FHR and fetal breathing
movements are the last centres to develop and
they are acutely sensitive to early hypoxia.

111. BPP
component
Centre in the
brain
Appearance
Fetal tone Cortex-
subcortical area
8 weeks
Fetal movement Centre in cortex
nuclei
9 weeks
Breathing
movements
Centre in the
ventral surface
of fourth
ventricle
21 weeks
FHR reactivity Posterior
thalamus and
medulla
Late 2nd T and 3rd T
( around 28
weeks).

112. COMPONENTS OF ACUTE
HYOXIA
• Changes in acute components reflect the integrity of
the regulatory centre and its response to hypoxia.
• Normal BPP- excludes fetal pathology due to
hypoxia.
• Abnormal BPP- hypoxia, quiet sleep, transplacental
passage of maternal sedatives or opiates.
• Gestational age,steroids also have impact on BPP.
• If more than one variable is absent its pathological.

113. COMPONENTS OF CHRONIC
HYPOXIA- AFV
• Sustained hypoxemia leading to selective
redistribution to brain,heart, adrenals and
placenta.
• Renal perfusion decreases followed by
decrease in urine output.
• Decreased AFI. If persists leads to
oligohydramnios and anhydramnios.

114. FREQUENCY OF TESTING
• BPP is repeated at weekly intervals.
• In the presence of high risk factors, repeat
twice weekly.
• An acute decrease in fetal activity,
deterioration of maternal condition warrants
retesting.
• RCOG does not recommend use of BPP or
MBPP in routine screening for pregnancy
complications.
• Normal BPP or MBPP does not exclude use
of intrapartum fetal monitoring.

115. • To perform a BPP, real time ultrasound is
used to observe the fetus over a
maximum period of 30 minutes and
either 2 points or 0 points are awarded
based on presence or absence of the
parameter.
• Maximum score is 10 points.
• Drugs like magnesium sulphate and
corticosteroids decrease FHR variability
and fetal breathing movements,but no
effect on fetal tone or AFI.

116. FETAL BREATHING
MOVEMENTS
Normal
• Intermittent multiple breaths in 30 minutes that
lasts more than 30 seconds.
Abnormal
• Continuous breathing without cessation.
• Completely absent breathing.
• No sustained episode of > 30 seconds.

117. • This fetal behavior is the one most easily suppressed
by hypoxemia, but it is also the most episodic in
normal fetuses.
• There is diurnal variation, breathing diminishes at
night.
• Normal fetus can have an apnea of 108 minutes.
• Low 5 minute APGARs & Fetal distress more
frequent when FBM absent.

118. FACTORS AFFECTING
BREATHING MOVEMENTS
Increased Decreased No
change
Controversial
•Maternal
glucose
administration
•Hypercapnea
•Increasing
gestational
age.
•Maternal
meals.
•Nicotine.
•Labour.
•Chorioamnionitis.
•PROM.
•Amniocentesis.
•MgSO4.
•Caffeine •Epidural.
•Oxytocin.

119. BODY MOVEMENTS
Normal
• At least 3 discrete movements in 30 minutes.
• It includes fine motor movements and rolling movements.
• Rapid eye movements or mouthing movements are not considered.
Abnormal
• Two or fewer body or limb movements in a 30 min observation period.

120. MOVEMENTS
• Swallowing
• Facial expressions
• Sucking
• Yawning
• Kicks
• Rolling movements
• When a fetus does not move for a period of 30
minutes, extended testing is performed.

121. FETAL TONE
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.
• Kicking.
Abnormal
• Low-velocity movement only.
• Incomplete flexion, flaccid extremity positions, abnormal fetal posture

122. BIOPHYSICAL PROFILE

123. INTERPRETATION
BPP score Implication PNM
risk
Management
10/10,8/10
(AFV normal),
8/ 8(NST not
done)
Risk of fetal
asphyxia
extremely rare.
1/1000 Intervention only for obstetric
and maternal factors.
8/10 with
abnormal fluid
Probable
chronic fetal
compromise
89/1000 Rule out renal anomalies,
PPROM.Consider steroids
and deliver.Intense
surveillance if <34 weeks
6/10 (AFV
normal)
Equivocal
test,asphyxia
not excluded
89/1000 Repeat testing, if 10/10 in 2
continuous 30 min periods
manage as 10/10.
If 6/10 is persistent deliver
mature fetus.in imature fetus
repeat within 24 hrs,if still
6/10 deliver.

124. Parameter
s
Implication PNM risk Management
4/10 Probable fetal
asphyxia,AFV –
abnormal – acute
on chronic
asphyxia very
likely
91/1000 Repeat testing
same day.
Deliver with
continuous
monitoring if
<6/10.
2/10 Acute fetal
asphyxia likely
with chronic
decompensation
125/1000 Deliver for fetal
indications.
0/10
Severe, acute
asphyxia.
600/100 Viable fetus-
deliver
immediately by
cesarean

125. INTERPRETATION OF BPP

126. MODIFIED BPP
• Modified BPP is performed commonly as it is quick
and components of BPP which disappear first along
with a chronic component are monitored.
• It consists of
• Recording an antenatal NST (with or without
vibroacoustic stimulation).
• Ultrasound measurement of amniotic fluid volume.

127. • Normal Modified BPP will occur in 90% of
pregnancies.
• A negative BPP or MBPP is reassuring in 99.9%
of cases, can be used for decision making about
conservative management.
• A positive test is indicative of fetal compromise
in only half of the cases.
• Rate of stillbirth within 1 week of a normal test is
same as BPP (0.8 per 1000 women tested).

128. NON STRESS TEST
• It is the commonly used tool for fetal assessment.
• It describes fetal heart rate accelerations in
response to fetal movement as a sign of fetal
health.
• Testing is started after 32 weeks and
recommended twice weekly in specific high risk
conditions.
• Loss of reactivity occurs in fetal sleep cycle, fetal
acidosis.

129. INDICATIONS FOR NST

130. PHYSIOLOGY
• It is based on the interplay between
sympathetic and parasympathetic nervous
system and impact on FHR patterns.
• Heart rate reactivity is a good indicator of
normal fetal autonomic system.
• Sympathetic system develops early in life,
parasympathetic system, develops in later
pregnancy.

131. • The variables of NST
• Baseline FHR- 110-160 bpm.
• Variability of the FHR
• Presence or absence of
accelerations
• Presence or absence of
decelerations

132. • Baseline FHR falls during 2nd trimester
upto 30 weeks, then remains stable for last
10 weeks.
• Fetal bradycardia occurs with acute
hypoxia,if severe and prolonged is a sign
of impending death.
• Moderate to severe hypoxia when
complicated by acidosis is associated with
reduction in variability and also absence of
accelerations.

134. • Usual time is 20 minutes.
• If extended to 40 minutes it is called as
EXTENDED NST.
• Non reactive NST occurs in
• Fetal asphyxia.
• Hypoxia.
• Preterm fetus.
• Depressants like narcotics,phenobarbitol.
• Beta blockers.
• Smoking.

135. • On initial testing, 85% of high risk women
show a reactive NST.
• NST is frequently non reactive, from 24-28
weeks , upto 50% NST may not be
reactive, from 28-32 weeks 15% NST are
non reactive.
• Variable decelerations if not repetitive and
brief – do not indicate fetal compromise.
• Decelerations lasting 1 minute or longer
has worse prognosis.

136. • The test has a false negative rate of
3.2/1000 and false positive rate is 50% for
morbidity and 80% for mortality.
• A reactive NST is predictive of good fetal
outcome for 1 week except in case of
IDDM and postdated pregnancy ,where
twice weekly NST done.
• But perinatal death is about 40 per 1000
when the NST is nonreactive.

137. FREQUENCY
• Daily
Severe preeclampsia.
• Twice weekly
Post term pregnancy.
IDDM.
FGR.
Multifetal gestation.
Gestational hypertension.

138. COMPUTERISED CTG
• The CTG information is analysed by a
computer to satisfy criteria of normality over a
period of maximum 60 min with first result
after 10 min and is updated every 2 min, but
analysis can be stopped if criteria are not met
before this time.
• Risk for fetal hypoxia/ acidemia is extremely
low if Dawes- Redman criteria for normality
are met.

141. VIBROACOUSTIC STIMULATION
• Reduces the testing time and false positive rate
for NST.
• In this test ,the fetus is stimulated in utero by an
artificial larynx which elicits a startle response
and effect of this response on fetal heart is
studied.
• Artificial larynx positioned near fetal vertex with
stimulus of 1-2 seconds.
• This may be repeated upto 3 times at 1 minute
intervals for a duration of 3 seconds.

142. • It differentiates normal fetal sleep and
asphyxia.
• Normal fetal response is accelerations in
FHR, increase in long term variability,
gross body movements.
• Combination of VAS and NST have higher
sensitivity in detecting abnormal outcomes
(66% vs 39%) compared to NST alone.
• Incidence of non reactive NST is reduced
from 14% to 9%.

143. VISUAL ACOUSTIC STIMULATION
TEST - VAST
• Utilises ultrasound to evaluate fetal response to acoustic stimulation.
 Observation time is maximum 10 minutes.
• Includes
• 1. Chronic response- Fetal growth, AFI.
• 2.Acute response- sympathetic response- startle
response, FH accelerations.
- behavioural state- breathing
movement, general body movements.

144. AMNIOTIC FLUID VOLUME
• Assessment of amniotic fluid is a chronic
marker of fetal well-being which is assessed
in 2nd and 3rd trimester.
• Amniotic fluid index and single deepest
pocket or the maximal vertical pocket are the
most common methods.
• Disruption of the process of amniotic fluid
production, removal and absorption cause
abnormal reduction or increase in AF volume.

145. AMNIOTIC FLUID INDEX
• Determined by the summation of the
vertical diameter of the largest pocket
in each of the four quadrants.

146. SDP
• It is the best choice for measurement
of amniotic fluid volume because use
of AFI increased diagnosis of
oligohydramnios, more labour
inductions, more cesarean delivery
without improvement in perinatal
outcomes.

147. INTERPRETATION OF MBPP
• Normal MBPP- NST reactive and AFI > 5 cm.
• Abnormal MBPP- either NST is non reactive or AFI <5 cm.
Reactive NST,
AFV normal
Weekly or twice weekly testing.
Reactive NST,
oligohydramnios
36 weeks- delivery.
<36 weeks- doppler with increased frequency
of testing.
Non reactive
NST, then BPP
is done.
Fetal breathing movements present- manage
according to AFV.
Breathing movements absent, normal
movements and tone- extend NST (120 min) or
repeat BPP or doppler.
All BPP parameters absent- deliver.

148. DOPPLER
• Fetal doppler is one of the best available tool
for fetal surveillance in high risk pregnancies.
• Routine doppler in low risk population does
not improve maternal or fetal outcome.
• Goal of doppler is to improve perinatal
mortality and morbidity.

149. VESSELS INTERROGATED
• Umbilical artery- done with serial growth scans
in high risk pregnancies.
• Middle cerebral artery.
• Aortic isthumus.
• Venous dopplers such as ductus venosus,
umbilical vein.
• Arterial doppler assess placental function and
fetal vasoregulation.
• Venous doppler assess fetal cardiac function.

150. Variable Location Gestatio
nal age
(weeks)
Pitfalls Abnormal
result
Adverse
outcome
Umbilical
artery
Free loop of
cord,placenta
l insertion
site.
>23 Optimal
when no
FBM
present.
Increased
resistance
, AEDF,
REDF.
stillbirth.,
neurologic
al
impairmen
t
Middle
cerebral
artery
Proximal one
third of the
vessel at 0
degree angle
of insonation.
>23 >30
degree
angle of
insonatio
n.
Increased
diastolic
flow.
Neonatal
acidosis,
neurologic
al
impairmen
t.
Ductus
venosus
Site where it
branches
from umbilical
vein.
>23 Obtainin
g IVC
doppler
Decrease
d,absent
or
reversed
flow in a
wave.
Neonatal
acidemia,
perinatal
mortality.

151. DOPPLER INDICES
• S/D ratio – Systolic/ Diastolic ratio.
• Resistance index (RI) – (peak systolic velocity-
lowest diastolic velocity) / peak systolic
velocity.(S-D)/ S.
• Pulsatility index (PI) - (peak systolic velocity-
end diastolic velocity) / mean peak systolic
velocity.
(S-D/mean S)

152. NORMAL UMBILICAL DOPPLER
Increase in number of vascular
channels, tunica media destruction,
trophoblastic invasion.
Decreased intraplacental vascular
resistance and increase in blood flow
velocity in umbilical artery.
Tall diastolic waves.
Low S/D ratio, PI and RI.

153. NORMAL UMBILICAL ARTERY

154. • Fetal circulation is a low resistance
system.
• Umbilical artery indices show reversed
flow when 70% of placental vascular tree
is not functioning.

155. MCA DOPPLER
• MCA is the most accessible cerebral vessels for evaluation.
• Carries more than 80% of blood flow.
• Cerebral circulation is a high resistance circulation.

156. MIDDLE CEREBRAL ARTERY

157. MCA DOPPLER IN FGR
• The cause of FGR is placental. There is
defective placentation with inadequate
invasion of trophoblasts.
• Fetus with hypoxia adapt their circulation to
utilise the available oxygen to preferential
organs such as brain,myocardium and
adrenals.
• The autoregulation of cerebral circulation
leads to vasodilatation and increased
cerebral flow (brain sparing effect).
• Decreased resistance in MCA.

158. CEREBROPLACENTAL RATIO
• It is used as a predictor of adverse
pregnancy outcome and is more sensitive to
fetal hypoxia.
• Abnormal CPR- reflects redistribution of
cardiac output to cerebral circulation.
• It is associated with intrapartum fetal
distress, increased rate of NICU admissions
and poor neurological outcomes.
• Cerebroplacental ratio is the ratio of MCA
PI/ UA PI.CPR < 1 suggests fetal
compromise, correlates better with adverse
outcome.

159. MCA PI < 5TH CENTILE AND CPR
< 1
Early onset FGR (<32
weeks) with abnormal
CPR
Late onset FGR (> 32
weeks) with abnormal
CPR
•Lower gestational age at
birth and low birth weight.
•High rate of cesarean
section.
•Increased rate of neonatal
acidosis, NICU admissions
and perinatal death.
•Increased risk of stillbirth
and perinatal loss.
•This finding is irrespective
of EFW or uterine artery
doppler.

160. AORTIC ISTHUMUS
• Technically difficult to sample reliably and
consistently.
• It reflects balance between fetal right and left
ventricular output.
• There is forward flow during diastole.
• In FGR, there is redistribution of cardiac output
leading to retrograde flow in diastole.

162. FETAL VENOUS DOPPLER
• Venous doppler reflects the physiological
status of right ventricle.
• After 15 weeks, umbilical vein normally
has continuous monophasic non pulsatile
forward flow.
• It becomes pulsatile during fetal breathing,
severe FGR, hydrops fetalis.
• In compromised fetus, flow is retrograde.
• IVC doppler waveforms are triphasic.

164. DUCTUS VENOSUS DOPPLER
• It is a unique blood vessel which shunts
highly oxygenated blood from umbilical
vein to right atrium.
• It has triphasic ,pulsatile forward flow.
• It has 2 peaks S,D followed by a nadir – a
wave.
• Reversal a wave signifies heart failure and
cardiac decompensation.

165. DUCTUS VENOSUS
Progressing FGR
Increase in RV afterload leads to decrease in venous
forward flow during RA contraction. Deepening of a wave.
Reversal of
ductus
venosus

166. Progressive fetal compromise secondary to
placental insufficiency
• Increased umbilical artery resistance
without centralisation of blood flow.
• Increased umbilical artery resistance with
centralisation of blood flow (brain sparing
effect).
• Absence of umbilical artery diastolic flow.
• Reversed umbilical artery diastolic flow-
ominous signs for delivery.
• Alteration in venous circulation- preterminal
event.

167. SEQUENTIAL CHANGES IN
BIOPHYSICAL PARAMETERS IN
HYPOXIA
• Non reactive NST
• Changes in doppler
• UA: decreased/absent/reversed end
diastolic flow.
• MCA: brain sparing effect.
• DV: abnormal flow.
• Changes in BPP
• Decreased fetal breathing,movement, gross
body movement,fetal tone.

168. ANTEPARTUM FETAL MONITORING
THROUGH A WEARABLE SYSTEM
AND A MOBILE APPLICATION.
Telefetalcare system comprises of a wearable unit,
compact electronic box for data processing/transmission, a
smart phone or tablet that send signals over to a remote
diagnostic centre and reviews the results

169. SPECIAL TESTS IN CERTAIN HIGH
RISK CONDITIONS

170. DIABETES
• Accurate ultrasound dating in first
trimester.
• Aneuploidy screening.
• Detailed fetal anomaly scan at 18-20
weeks, fetal echo at 22-24 weeks.
• Fetal growth monitoring at 28,32,36
weeks.
• NST can be done from 32 weeks.
• BPP and doppler velocimetery can be
done in case of FGR.

171. MULTIPLE PREGNANCY
• Accurate dating scan with assessing chorionicity and amnionicity.

172. MONITORING OF
MONOCHORIONIC TWIN

173. MONITORING OF
DICHORIONIC TWIN

174. Mild
gestational
hypertension
Severe
Gestational
hyertension
Pre-
eclamp
sia
Chronic
hypertensio
n
Fetal
monit
oring -
NICE
•USG for
growth,AFI, Umb
A doppler at
diagnosis and
every 2-4 weeks
before 34 weeks
•Diagnosis after
34 weeks USG
only for clinical
concerns.
•CTG if clinically
indicated.
•CTG ,USG for growth,
AFI, Umb A doppler at
diagnosis if
conservative
management planned.
Repeat once in 2
weeks.
•NST at diagnosis and
then only if clinically
indicated.
•Repeat CTG in case
of decreased fetal
movements,vaginal
bleeding,abdominal
pain,maternal
condition deterioration
Same as
severe
gestationa
l
hypertensi
on.
•Dating scan,
ultrasound at
18-20 weeks,
fetal
growth,AFI,
Umb A doppler
at 28-weeks,32
weeks and 36
weeks.
•CTG olny if
clinically
indicated.

175. HYPERTENSIVE DISORDERS OF
PREGNANCY
Gestational
hypertension
Pre-
eclampsia
Chronic
hypertension
Monitoring -
ACOG
CTG, BPP
initially
followed by
CTG weekly ,
USG every 3
weeks.
USG
(AFI,EFW),
NST ,BPP
initially.
CTG twice
weekly with
BPP if CTG is
non reactive.
USG for
growth every 3
weeks.
Ultrasound
same as
RCOG,
Modified BPP
twice weekly
after 32
weeks.

176. POSTDATED PREGNANCY
• MBPP is done twice weekly between 40 and
42 weeks.
Normal NST Low 1st min APGAR - 1.9%
CS risk - 3.3%
Neonatal morbidity -
infrequent
Abnormal NST Low 1st min APGAR -12.5%
CS risk - 22%
Neonatal morbidity - 19%

177. FETAL GROWTH
RESTRICTION

178. SURVEILLANCE FREQUENCY IN FGR
Early onset FGR Minimum surveillance frequency
UA doppler >95th
centile
Every 2 weeks doppler, weekly BPP
or cCTG
Low MCA PI or CPR Weekly doppler with BPP or cCTG
UA- AEDF Admission, twice weekly doppler with
BPP or cCTG
UA- REDF, increased
DV or oligohydramnios
Admission, 3 times/week doppler
with BPP, daily CTG
Absent or reversed DV
a wave
Daily doppler with BPP or cCTG
Late Onset FGR
UA PI >95th centile Weekly doppler with BPP
Low MCA PI or CPR 2-3 times/ week doppler with BPP

180. RH ALLOIMMUNISATION

184. THANK YOU