ASSESMENT OF UTERINE GROWTH

FETAL MOVEMENT COUNT NONSTRESS TEST CONTRACTION STRESS TEST BIOPHYSICAL PROFILE MODIFIED BIOPHYSICAL PROFILE DOPPLER VELOCIMETRY

Deoxygenated blood arrives at the placenta via umbilical arteries

Returned to fetus via umbilical vein with partial pressure 4.7kpa or 35-40mmHG and 8090% saturation

Between 50-60% of this placental venous blood bypasses hepatic circulation via ductus venosus to enter IVC

AT THE JUNCTION OF IVC AND RIGHT ATRIUM IS A TISSUE FLAP KNOWN AS EUSTACHIAN VALVE

This valve tends to direct more highly oxygenated blood streaming along IVC, FORAMEN VALVE in to left atrium Oxygen saturation in the left atrium s 65%

ADEQUATE OXYGENATION TO THE FETUS BY

- HIGH CARDIAC OUTPUT-170 ml/kg/min - CENTRAL SHUNTING MECHANISM

- FETAL HAEMOGLOBIN WHICH HAS HIGHER AFFINITY FOR OXYGEN

CENTRALIZATION OF BLOOD FLOW

INCREASED PLASMA HAEMOGLOBIN CARDIAC DYSFUNCTION AND IRREVERSIBLE NEUROLOGICAL DAMAGE IN SEVERE HYPOXIA

SINGLE GOAL DETECTION OF CHRONIC FETAL HYPOXIA

Reduce the incidence of fetal death Minimize morbidity by optimizing the timing of delivery Identify more clearly those fetuses genuinely at risk of chronic hypoxia and avoiding unnecessary interventions Identifying those fetuses at risk of acute hypoxia in labour

MATERNAL

HYPERTENSIVE DISORDERS DIABETES CHRONIC RENAL DISEASE ANTIPHOSPHOLIPID ANTIBODY SYNDROME AND OTHER AUTOIMMUNE DISEASES CYANOTIC HEART DISEASE INADEQUATE NUTRITION SMOKING

IUGR RECURRENT ABRUPTION PREECLAMPSIA ABNORMAL AMNIOTIC FLUID VOLUME REDUCED FETAL MOVEMENTS ABDOMINAL PAIN WITH OUT A CLEAR CAUSE POSTDATES PREGNANCY PREVIOUS STILLBIRTH PREVIOUS IUGR

Gestation at which these tests should be initiated depends largely on the prognosis for fetal survival should intervention be required owing to an abnormal test result PRACTICAL FETAL VIABILITY
IDEALLY AT 32 34 WEEKS GESTATION - 26-28 WEEKS OF GESTATION IN HIGH RISK CASES

Between 20 and 34 weeks height of uterine fundus measured in cm correlates with gestational age in weeks
the rule of thumb is lag of growth greater than four cm.

Fundal height should be measured as the distance over the abdominal wall from the top of symphysis pubis to the top of the fundus
Bladder must be emptied before the measurement Dextorotation should not be corrected Abnormalities of fundal height should lead to further investigation Accuracy very poor

NUMBER OF KICKS PER HOUR 31

PERMISSIBLE PERIOD OF ABSENT FETAL MOVEMENTS IN

HEALTHY FETUS UP TO 75 MINUTES

Mean time to appreciate ten fetal movements is 20.9

minutes

FHR ACCELERATIONS PER HOUR IN HEALTHY FETUS 34

LONGEST TIME BETWEEN SUCCESSIVE FHR ACCELERATIONS 37 MINUTES , UP TO 80 MINUTES

NORMAL

FETAL TONE

- 7.5 8.5 WEEKS

FETAL MOVEMENT FETAL BREATHING

9WEEKS

- 20-21 WEEKS

FETAL HEART RATE ACCELERATIONS- 2428 WEEKS

STATE 1F - quiescent state quiet sleep with a narrow oscillatory bandwidth of fetal heart rate
STATE 2F frequent gross body movements , continuous eye movements, wider oscillation of fetal heart rate REM OR ACTIVE SLEEP in the neonate STATE 3F continuous eye movements in the absence of body movements and no heart rate accelerations STATE 4F VIGOROUS BODY MOVEMENTS with continuous eye movements and heart rate accelerations

1ST sign of reduced blood supply by which fetuses conserves its energy
It is the simplest and least costly method Most studies initiate fetal movements after 28-32 weeks of gestation Women perceived 16 movements

80 % of actual fetal

Fetal movements were found to be increased between 9pm and 1 am

Fetal movements perceived best when lying down Maternal exercise does not alter fetal activity
Most studies did not show increased movements after food or glucose

Most commonly used method is the cardiff method

< 10 movements in 12 hrs abnormal

Cardiff count method too conservative will not allow early detection of fetal hypoxia
MOORE AND PIACQUADIO

10 movements in 2 hrs normal

NELDAM Women are instructed to count fetal movements for 1 hour a day and the count is accepted as reassuring if it equals or exceeds a previously established baseline count

ACOG
- PERCEPTION OF TEN DISTINCT MOVEMENTS IN UP TO 2 HRS CONSIDERED REASSURING - COUNTING CAN BE DISCONTINUED FOR THAT DAY AFTER TEN MOVEMENTS

Low risk women with reduced fetal movements

All high risk women with reduced fetal movements Fetal movements < 10 in 2 hrs

NST

REACTIVE

NONREACTIVE

WITH NO RISK FACTORS CONTINUE WITH FETAL MOVEMENT COUNT

WITH RISK FACTORS FURTHER STUDY WITH BPP OR MBPP

BPP OR DOPPLER AS CASE DEMANDS

Reflection of CNS ALERTNESS AND ACTIVITY

Non invasive ,easily performed and interpreted , readily acceptable by the patients Temporary Acceleration of fetal heart rate occur with response to fetal movement Normal FHR accelerations in the presence of significant cerebral anomalies suggested that NST DEPENDENT UPON ONLY ON BRAINSTEM IN THE BRAIN ALSO

Regulation of FHR due to balance between sympathetic and parasympathetic nervous system

Place the patient in semifowlers or left lateral tilt position Apply external monitor to the maternal abdomen and observe FHR RECORDING
recording continued for 20 minutes

REACTIVE when there are two or more accelerations of FHR of 15 beats per minute for atleast 15 seconds duration over a 2o minute recording after 32 weeks

IN PRETERM FETUSES an acceleration of FHR of 10 beats/ minute or more above the base line lasting 10 seconds or longer In extreme preterm fetuses with immature CNS . NST has no role

NON REACTIVE
LACK OF ACCELERATIONS FOR A PERIOD OF 40 MINUTES Most common cause of non reactive fetus fetal inactivity prematurity

High false positivity rate 50% and

Low positive predictive value can lead to unnecessary intervention FALSE NEGATIVE RATE IS VERY LOW 3.2 PER 1000

If the pattern is nonreactive after 20 minutes of observation then vibroacoustic stimulation (VAS), using an artificial larynx, may be performed.
The acoustic stimulator should be positioned on the maternal abdomen and a stimulus of 3 sec or less applied near the fetal head. If the NST remains nonreactive, the stimulus is repeated at 1-minute intervals up to three times.

Healthy fetuses respond with sudden movement followed by FHR Acceleration

Fetus < 24 weeks do not respond 24 27 weeks- 30% of fetuses respond

27 30 weeks 86% of fetus respond

> 37 weeks 96% of fetuses respond

Response of fetal heart rate accelerations to uterine contractions

Uteroplacental blood flow decreases during uterine contractions Healthy fetus tolerate the stress with out difficulty for 2-3 minutes

Hypoxic fetus will manifest late decelerations

Test requires 3 contractions lasting 40- 60 seconds with in 10 minute period If uterine activity absent stimulate with oxytocin 0.5 miu/minute
Double the rate every 15 20 minutes

RESULT: no late or significant variable decelerations

POSITIVE: late decelerations following 50% or more of contractions EQUIVOCAL SUSPICIOUS : intermittent late decelerations or significant variable decelerations EQUIVOCAL HYPERSTIMULATORY UNSATISFACTORY

Classical caesarean section Extensive uterine surgery Placentaprevia Preterm labour Preterm rupture of membranes Multiple gestation

It is rarely performed due to longer duration of the test Requirement for continuous supervision by trained personnel and existence of risks and contraindications associated with its performance False negative rate is 0.4 per 1000

A NON REACTIVE NST THAT REQUIRES A BIOPHYSICAL PROFILE TO BE DONE

Introduced in 1980 by MANNING Assigns a maximum of two points to each of five variables 1. fetal breathing 2. fetal movement 3. fetal tone 4. qualitative amniotic fluid 5. NST Recorded for 30 minutes

Component

Definition
Two or more fetal heart rate accelerations peak (but do not necessarily remain) at least 15 beats per minute above the baseline and last 15 seconds from baseline to baseline within a 20-minute period with or without fetal movement discernible by the woman. A single 2 cm x 2 cm pocket is considered adequate or AFI greater than 5.0 cm . One or more episodes of rhythmic fetal breathing movements of 30 seconds or more within 30 minutes. Hiccups are considered breathing activity. At least three discrete body or limb movements. Episodes of continuous movement are considered as a single movement. One or more episodes of extension of a fetal extremity or trunk with return to flexion, or opening or closing of a hand

Non-stress test

Amniotic fluid volume Fetal breathing movements

Fetal movements

Fetal tone

Normal BPS SCORE OF 8 OR 10 with normal amniotic fluid indicative of healthy fetus
Even a good score with low AFI carries high risk to the fetus

Score of 8 due to reduced amniotic fluid high risk for chronic compensated hypoxia either delivered or repeat the BPS not less than twice a week
A BPS of 6 EQUIVOCAL INDIVIDUALIZED A BPS of 4 or less immediate delivery

Perinatal Mortality and the Biophysical Profile Score

Score 8- 10 6

Interpretation Normal Equivocal

Perinatal Mortality/1000 1.86* 9.76

4 2
0

Abnormal Abnormal
Abnormal

26.3 94.0
285.7

*The perinatal mortality is 0.8/1000 for structurally normal fetuses with a normal test within 7 days.

FETOMATERNAL HAEMORRHAGE
UMBILICAL CORD ACCIDENTS ABRUPTION

False positivity rate is 30% False negative rate is 0.7 per 1000 Positive predictive value better than of NST

Excellent test for primary fetal surveillance An index of acute fetal hypoxia and chronic fetal problems
Combines NON STRESS TEST AND AMNIOTIC FLUID INDEX.

Performed in an average of twenty minutes It has excellent negative and positive predictive values
EASILY INTERPRETED

If both NST AND FLUID VOLUME normal weekly fetal surveillance

Both tests abnormal - pregnancy > 36 weeks DELIVERY

Pregnancy less than 36 weeks management is individualized

IF AMNIOTIC FLUID VOLUME decreased with reactive NST - to rule out placental insufficiency or undiagnosed rupture of membranes If NST non reactive further testing with DOPPLER OR FULL BPP

Decreased uteroplacental perfusion Diminished fetal renal flow Decreased urine production Oligohydramnios

Amniotic Fluid Index (AFI) The amniotic fluid index is measured by dividing the uterus into four quadrants

The linea nigra is used to divide the uterus into right and left halves.
The umbilicus serves as the dividing point for the upper and lower halves. The transducer is kept parallel to patients longitudinal axis and perpendicular to the floor. POCKETS consisting primary of umbilical cord are disregarded

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