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 ASSESMENT OF UTERINE GROWTH  FETAL MOVEMENT COUNT  NONSTRESS TEST  CONTRACTION STRESS TEST
  • 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

Deoxygenated blood arrives

at the placenta via umbilical

arteries

Returned to fetus via umbilical

vein with partial pressure 4.7kpa or 35-40mmHG and 80- 90% 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 -

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
  • CENTRALIZATION OF BLOOD FLOW

  • INCREASED PLASMA HAEMOGLOBIN

  • CARDIAC DYSFUNCTION AND IRREVERSIBLE NEUROLOGICAL DAMAGE IN SEVERE HYPOXIA

 SINGLE GOAL – DETECTION OF CHRONIC FETAL HYPOXIA
  • SINGLE GOAL DETECTION OF CHRONIC FETAL HYPOXIA

 Reduce the incidence of fetal death  Minimize morbidity by optimizing the timing of delivery
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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 9WEEKS

  • FETAL BREATHING - 20-21 WEEKS

  • FETAL HEART RATE ACCELERATIONS- 24- 28 WEEKS

 STATE 1F - quiescent state – quiet sleep with a narrow oscillatory bandwidth of fetal
  • 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

 1 sign of reduced blood supply by which fetuses conserves its energy  It is
  • 1 ST 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 80 % of movements

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

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
Low risk women with
reduced fetal movements
All high risk women with reduced fetal movements
All high risk women with
reduced fetal movements
Fetal movements < 10 in 2 hrs
Fetal movements < 10 in 2
hrs
NST REACTIVE NONREACTIVE WITH NO RISK FACTORS CONTINUE WITH FETAL MOVEMENT COUNT WITH RISK FACTORS FURTHER
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
  • 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 semifowler’s or left lateral tilt position  Apply external monitor to
  • Place the patient in semifowler’s 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
  • 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
  • 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
  • If the pattern is nonreactive after 20 minutes of observation then vibroacoustic

stimulation (VAS), using may be performed.

an artificial larynx,

  • 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
  • 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
 RESULT: no late or significant variable decelerations  POSITIVE: late decelerations following 50% or more
  • 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
  • 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
  • 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
  • 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

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 Non-stress test Two or more fetal heart rate accelerations peak (but do not necessarily

Component

Definition

Non-stress test

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.

Amniotic fluid volume

A single 2 cm x 2 cm pocket is considered adequate or AFI greater than 5.0 cm .

Fetal breathing

One or more episodes of rhythmic fetal breathing movements of 30 seconds or more within 30 minutes.

movements

Hiccups are considered breathing activity.

Fetal movements

At least three discrete body or limb movements. Episodes of continuous movement are considered as a single movement.

Fetal tone

One or more episodes of extension of a fetal extremity or trunk with return to flexion, or opening or closing of a hand

 Normal BPS – SCORE OF 8 OR 10 with normal amniotic fluid – indicative of
  • 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 Interpretation Perinatal Mortality/1000 8- 10 Normal 1.86* 6

Perinatal Mortality and the Biophysical Profile Score

Score

Interpretation

Perinatal Mortality/1000

8- 10

Normal

1.86*

6

Equivocal

9.76

4

Abnormal

26.3

2

Abnormal

94.0

0

Abnormal

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
  • 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
  • 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 -
  • 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
  • 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

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 patient’s

longitudinal axis and

perpendicular to the floor.

POCKETS consisting primary of umbilical cord are disregarded

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

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