Biophysical profile

Ultrasound A biophysical profile is a prenatal ultrasound evaluation of fetal well-being, involving a scoring system.[1] It is often done when a non-stress test is non reactive, or for other obstetrical indications. The test The biophysical profile (BPP) has 5 components: 4 ultrasound (US) assessments and a nonstress test (NST). The nonstress test (NST) (CTG) evaluates fetal heart rate and response to fetal movement. The five discrete biophysical variables: 1. Fetal movement 2. Fetal tone 3. Fetal breathing 4. Amniotic fluid volume 5. Fetal Heart Rate

Parameter

Normal (2 points)

Abnormal points)

(0

Less than two At least two NST/Reactive accelerations to accelerations in 30 FHR satisfy the test in minutes 30 minutes At least one US: Fetal episode of > None or less than [citation needed] needed] breathing 30s or 30s[citation or [2] [2] movements >20s in 30 20s minutes US: Fetal activity / gross body movements At least Less than [2] two movements [citation needed] three or of the torso or [2] two movements limbs

US: Fetal At least No movements or [2] muscle tone one episodes of movements slow active bending and and incomplete straightening of the

limb or trunk At least one vertical pocket> 2 cm or Largest vertical more in the vertical pocket</=2cm axis

US: Qualitative AFV/AFI

Use of acoustic stimulation to accelerate evaluation has been described.[3] Scoring Each assessment is graded either 0 or 2 points, and then added up to yield a number between 0 and 10. A BPP of 8 or 10 is generally considered reassuring. A BPP normally is not performed before the second half of a pregnancy, since fetal breathing movements do not occur in the first half. The presence of these biophysical variables implies absence of significant central nervous system hypoxemia/acidemia at the time of testing. By comparison, a compromised fetus typically exhibits loss of accelerations of the fetal heart rate (FHR), decreased body movement and breathing, hypotonia, and, less acutely, decreased amniotic fluid volume.

Definition The fetal biophysical profile (BPP) is a test performed to measure fetal well-being. It uses ultrasonography to measure fetal breathing, fetal movement, fetal tone, and amniotic fluid volume. A non-stress test is done to assess fetal heart rate. Each of these five variables is given a score of zero or two, for a potential total score of 10. Purpose The purpose of the BPP is to assess fetal well-being. It is a tool used near or at term by clinicians to assess the potential risk of fetal compromise or demise due to fetal hypoxia or acidosis. Intervention such as maternal hospitalization, or delivery may follow a BPP score of four or below. Precautions A reliable BPP score necessitates that a well-trained ultrasonographer perform the test. However, fetal parameters are recorded over a 30-minute time period, with an additional 30 minutes for the non-stress test (NST) component. Information on a very active fetus is obtained inconsiderably less time. The complete BPP can therefore be a time-consuming test. The NST records the relationship of fetal heart rate to fetal movement. It is associated, however, with a false-positive rate as high as 80%, and averaging about 50%. Description The BPP is a test scoring five fetal vital sign variables: fetal heart rate, fetal breathing, fetal movement, fetal tone, and amniotic fluid volume. An ultrasound is used to visualize the fetus to measure these variables. The fetal heart rate is assessed through an NST. Each parameter is given a score of two or zero, based on specific criteria. The total potential score is a 10. The BPP may be ordered following a non-reactive NST; after a suspicious oxytocin challenge/contraction stress test (CST); or after term, especially if there is concern about low amniotic fluid volume (oligohydramnios). The first researchers to report

the results of scoring these fetal biophysical variables as a group were Manning and colleagues in 1980. Fetal breathing (FB) is measured by watching for movement of the fetal thorax and diaphragm. This is to assure breathing, and not just chest wall movement. A score of two is given if at least one occurrence of FB lasting at least 30 seconds during the 30-minute test is noted. A score of zero is given if no FB is seen, or if the FB lasted less than 30 seconds. Fetal movement is defined by gross arm, leg, or body activity. A score of two is given if there are at least three separate limb/body movements during the 30-minute test. A score of 0 is given if there are two or fewer limb/body movements during the test. Facial movement is not scored. Fetal tone is defined by active extension and flexion of the fetal limbs, trunk, or hand; or if the hand remains in a flexed position during the entire 30-minute test. A score of two is given if the hand and fingers are seen to fully extend and flex into a fist. A score of zero is given if no such movement is recorded, or with slow or partial flexion or extension. Amniotic fluid volume is estimated for sufficiency. Since fetal anatomic structures do not allow full visualization of all the amniotic fluid, it is estimated by measuring pockets of fluid from 0.39 to 0.78 in (1 to 2 cm) in height on ultrasound. A score of two is given if at least one pocket of fluid measures 0.78 in (2 cm) or more in height. A score of zero is given when no such pockets can be measured. Normal amniotic fluid volume peaks at about 750 ml at 32 weeks gestation, stays stable until term at 40 weeks, and then declines to about 400 ml by 42 weeks. Excessive amniotic fluid amounts (hydramnios), such as might be seen in diabetic mothers, may be as high as 1700 to 1900 ml. Oligohydramnios is defined by about 300 ml of fluid volume. The amniotic fluid is produced as the fetus urinates and through lung secretions. The volume is controlled by fetal swallowing and by reabsorption through the membranes. The amniotic fluid index (AFI) is also used to determine sufficiency of

amniotic fluid. In this method, the largest vertical column of fluid in each of the four uterine quadrants is measured. Because of the role of the fetus in the production and control of amniotic fluid, it is one variable in fetal wellbeing assessment. Fetal heart rate (FHR) variability is measured during a NST. The fetal heart rate is normally variable in nature. Accelerations, or increases in FHR, are usually seen in response to fetal movements and are therefore reassuring. A score of two is given for two or more accelerations of at least 15 beats per minute that last at least 15 seconds each during a 30minute period. A score of 0 is given if fewer than two accelerations are seen within 30 minutes. Preparation Because the BPP is done during the third trimester of pregnancy, there is sufficient amniotic fluid to provide contrast to clearly visualize the fetus. No preparation is usually required before the test is performed. The mother may be asked to have a snack prior to the test to encourage a more active fetus. Because the mother's abdomen is exposed, curtains or a closed door should provide privacy. A comfortable room air temperature and the warming of the transducer gel can assist in putting the mother at ease. The mother should be asked if she wants her partner or support person with her during the test. A towel or cloth should cover the mother's clothing to avoid its getting wet from the transducer gel. Aftercare The BPP uses an external transducer to visualize the fetus and the amount of amniotic fluid. A towel or cloth can be used to wipe off excess gel and dry the abdomen after the test. In the event that test results indicate fetal compromise, a health care professional should remain with the mother to provide emotional support and answer questions as needed.

Complications Because the test is noninvasive in nature, complications from the test itself are unexpected. A non-reassuring test may be repeated four to 24 hours later for comparison. Efforts should be made to assess for false negatives or false positives. A low BPP score may be followed by interventions with their own potential complications. Results A score of eight or ten out of ten provides a reassuring BPP score. If the score is eight, with a decrease in amniotic fluid volume, delivery may be indicated, with fetal maturity. A score of six arouses suspicions of chronic fetal hypoxia. A repeat test within four to six hours may be ordered. Delivery may be indicated if there is a reduction in the amniotic fluid volume. A score of four is suspicious of chronic fetal hypoxia. A fetal lung maturity test may be done to assess readiness for delivery. Delivery is indicated if a repeat BPP after 24 hours confirms a score of four or below. A score of zero to two elicits a strong suspicion of chronic fetal hypoxia. The BPP testing period may continue for two hours instead of the usual 30 minutes. If the two-hour score is four or below, delivery is indicated if the fetus has a good chance at extrauterine survival. Health care team roles The BPP should be performed by a trained ultrasonographer. The NST may be performed by a nurse or a radiology technician in the antenatal division of an obstetric department, in the radiology department, or in an obstetric office. As with any test, patient anxiety is heightened with concerns of fetal compromise. Therefore, the ability of the health care professional to convey accurate information in a calming manner is very important.