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19 views6 pages

antenatal

Uploaded by

yiusefsar
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Antepartum fetal surveillance

Indications for antenatal surveillance

Maternal Conditions • Placental Conditions


Cyanotic heart disease Antiphospholipid antibody syndrome
Chronic renal disease Systemic lupus erythematosus
Hyperthyroidism Thrombophilia
Diabetes Hypertensive disorders, including pregnancy-
induced hypertension
Symptomatic
Marked placental anomalie
heamoglopinopathy

Fetal conditions

Decreased fetal movement Others

Amniotic fluid abnormalities In vitro fertilization pregnancy

(Oligohydramnios, Polyhydramnios) Previous stillbirth

Intrauterine growth restriction Prior neurologic injury

Macrosomia Previous recurrent abruption

Post-term pregnancy Obesity

Alloimmunization

Fetal anomalies or aneuploidy

Multiple gestation

When to initiate fetal surveillance


The American College of Obstetricians and Gynecologists, suggest starting monitoring at 32 to 34 weeks.
If the threshold of viability at a tertiary institution is 24 weeks and the presentation is severe like fetal growth
restriction, monitoring is likely to be started early.
Tests should be repeated at least weekly or more frequently according to the test and the severity of the
condition.
1- Fetal movement count
Kick counts are easy to perform, inexpensive, convenient, and keep the patient aware of her fetus usual
behavioral pattern.
Maximal activity is between 28-32 weeks gestation .
Gradual reduction toward term:
- due to the fetus/amniotic fluid volume ratio.
- maturing fetus with longer sleep cycles.
Highest incidence of fetal movement usually occur in the late evening.
Reassuring fetal kick count defined as:
-Perception of at least 10 FMs during 12 hours of normal maternal activity.
-Perception of least 10 FMs over 2 hours when the mother is at rest
2-Non Stress Test (NST)
• Assess the fetal heart rate (FHR) in response to fetal movement.
• This is based on the hypothesis that the HR for fetus who is not acidotic will
temporarily accelerate in response to fetal movement.
• NST is also affected by fetal state and maturation, maternal state and medications, and
diurnal biorhythms.
Interpretation:
Baseline FHR (Normal baseline rate is between 110 and 160 bpm .)
FHR variability (beat to beat variation)
Acceleration
Deceleration
The test is reactive if there are 2 or more fetal heart rate
accelerations reaching a peak of at least 15 bpm above
the baseline rate and lasting for at least 15 seconds from
onset to return in a 20-minute period.
The nonreactive NST result is defined by an FHR
monitoring interval that does not meet the criteria
previously
described. defined as one that does not show such accelerations
over a 40-minute period.( due to sleep cycle = every 40 minute)
Nonreactive NST can be due to fetal immaturity, quiet fetal sleep, or maternal smoking .
3-Biophysical Profile (BPP)
The BPP relies on hypothesis that multiple parameters of fetal well-being are better predictors of outcome
than any single parameter.
Includes 5 variables , with a total possible score of 10.
The BPP combines :
- NST
- Ultrasonographic estimation of amniotic fluid volume
- Assessments of fetal breathing
- Fetal body movements
- Fetal tone

advantages:
It is noninvasive.
Easily learned and performed.
Accurate mean for predicting the presence of significant fetal acidemia, which is the most common cause of
fetal death.
Assesses indicators of both acute hypoxia (NST, breathing, body movement) and chronic hypoxia (AFV).
The risk of fetal death within one week of a normal biophysical assessment is estimated to be 1 in 1300.
A reassuring BPS ( BPS of 8 to 10) should be repeated periodically (weekly or twice weekly) until delivery
when the high-risk condition persists.
Frequency of testing increases in direct proportion to the severity of the maternal or fetal condition.

4-Modified Biophysical Profile


The modified biophysical profile was developed to simplify the examination and reduce the time necessary
to complete testing.
Assessment of amniotic fluid volume and non stress testing appears to be as reliable predictor of long-term
fetal well-being as the full BPP.
If either the NST or the AFI is abnormal, a complete BPP or CST is performed.
The rate of stillbirth within one week of normal test is the same as with full BPP, 0.8/1000 .

5-Doppler Velocimetry
Measurement of blood flow velocities in the maternal and fetal vessels gives information about utero-
placental blood flow and fetal responses to physiologic challenges.
Non-invasive technique .
Vessels that can be studied :
- Uterine artery ( mother)
- umbilical artery (baby) most important
- Middle cerebral artery (baby)
- Ductus venosus (baby)
- Umbilical vein (baby)
Umbilical artery
the umbilical arteries purely reflects resistance of the placental circulation.
Normal umbilical artery resistance falls progressively through pregnancy, reflecting the increased numbers of
tertiary stem villous vessels.
Umbilical artery Doppler is beneficial in the management of high-risk pregnancies, especially those
complicated by fetal growth restriction and placental insufficiency due to preeclampsia or maternal
conditions.

The most important prognostic feature of the umbilical artery waveform is the end-diastolic flow.
As umbilical artery resistance rises ,diastolic velocities fall and ultimately become absent ( absent end
diastolic velocity AEDV).
As resistance rises even further, an elastic component is added, which induces reversed end-diastolic velocity
(REDV) as the insufficient, rigid placental circulation recoils after being distended by pulse pressure

Middle cerebral artery


In the compromised fetus, systemic blood flow is redistributed from the periphery to the brain, "brain-sparing
effect” . Adrenal , heart
Doppler assessment of the fetal middle cerebral artery peak systolic velocity has emerged as the best tool for
predicting fetal anemia in at-risk pregnancies.
Umbilical Vein
Blood flow in the umbilical vein is continuous in normal
pregnancies after 15 weeks of gestation.
In pathological states, such as fetal growth restriction
, flow in the umbilical vein may be pulsatile, which
reflects cardiac dysfunction related to increased afterload.
Ductus Venosus
The ductus venosus regulates oxygenated blood in the fetu
s , and is resistant to alterations in flow except in the most
severely growth restricted fetuses.
Ductus venosus deterioration frequently precedes
and strongly predicts changes in BPP that require delivery
6- Contraction stress test ( CST)
The contraction stress test (CST) is usually performed using oxytocin (also called oxytocin challenge test
OCT.
A diluted solution of oxytocin is infused until 3 contractions occcur within 10 minutes.
It evaluates the response of the fetal heart rate to induced contractions and was designed to unmask poor
placental function.
This is based on the theory that uterine contractions transiently worsen fetal oxygenation, leading to FHR
deceleration in a marginally compromised fetus with a limited placental function.
Positive CST if late decelerations occur with more than 50% of the induced contractions (even if the goal of
three contractions in 10-minutes has not yet been reached)
Negative CST has a normal baseline fetal heart rate tracing without late decelerations.
An equivocal test is defined as repetitive decelerations, not late in timing or pattern.

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