Antepartum fetal serveillance

Getachew Shiferaw (MD)

June 2011

Objective

Describe methods of fetal

surveillance
Describe significance of surveillance
Know indications of surveillance

Introduction

With current advances in perinatal medicine the

fetus has emerged a patient in utero. 80% fetal
death occur in the antepartum
Many antepartum deaths occur in women at risk
for uteroplacental insufficiency
Ideal test: allows intervention before fetal death or
damage from asphyxia
Preferable: treat disease process & allow fetus to
go to term
Objective- prevention of PNM

Techniques of evaluation
Early pregnancy:
1.
Biochemical:
a. Maternal serum alpha-fetoprotein (MSAFP):
Oncofetal protein produced by yolk sac &
fetal liver
Fetal & amniotic fluid level is highest at 13
weeks & then after decreases while
maternal serum level peaks at 32 weeks
Level of 2.5 MoMs when adjusted for
maternal weight is taken as cut off point

Elevated in a number of conditions like:

Wrong gestational age
Open neural tube defects
Multiple pregnancy
IUFD
Anterior abdominal defects
Renal anomalies
Lower levels are found in trisomies and GTD
Elevated level detects 85% of neural tube
defects followed with ultrasound &/or
amniocentesis

b. Triple screen test: MSAFP, hcG &

unconjugated estriol at 15-18 weeks
- Used for detection of Downs syndrome with
low MSAFP & unconjugated estriol but the
hcG level is elevated.
c. Acetylcholinesterase (AchE): Elevated in
most neural tube defects
d. Nuchal translucency: by ultrasound

e.

Prenatal genetic diagnosis:

amniocentesis, chorionic villous
sampling & cordocentesis
For cytogenetic analysis
DNA analysis for single gene
disorders

Techniques in Late pregnancy

1.

2.

Clinical

Careful risk evaluation of the pregnancy

SFH measurement GA-SFH-(18-30 wk), discrepancy-23wk

Serial measurement of weight

Auscultation of fetal heart sound

Abdominal girth measurement

U/S
GA assessment, DX of multiple pregnancy, congenital
malformation, fetal growth pattern
Biochemical methods Estriol, HPL, Amniocentesis

Techniques of evaluation
3.

Biophysical methods

Fetal movement counting

Antepartum fetal heart rate testing

NST, VAS & CST

Fetal biophysical profile

Doppler U/S

Fetal biophysical activities are initiated,

modulated & regulated through fetal
nervous system.
Fetal CNS is sensitive to diminished
oxygen
Fetus has different states like 1F, 2F, 3F &
4F
Fetal state-quiet sleep(1F)-25% of time
active sleep(2F)-60-70%
Near term - active sleep(40 min),
- quiet sleep(20 minutes)

Effect of hypoxia
Fetal hypoxemia
(asphyxia)
Celluar dysfunction

Aortic body
Chemoreceptor

Reflex late deccel

Hypotonia
Absent FBM
Absent GBM
NRNST

Redistr. CO

Increased BF
Decr. BF
- Fetal brain(IVH) -Fetal kidneys(Oligo)
- Adrenal
-Lungs(RDS)
-Heart
- Gut(NEC)
- Placenta
-Liver
&carcass(IUGR)

**Adapted from medicine of mother & fetus,1999

Fetal body movement

Maternal perception of ed in fetal

movements may be a sign of
impending fetal death
Maternal perception of FBM correlates
with US observed FBM b/n 28- 43 wks
of GA
Role - first line screening of low risk
pregnancies

Fetal body movement contd

Methods
Count for 30 - 60 min, 2-3x / day - / each day
- < 3 movement / hr
Count for at least 60 min / each day
< 3 movement / hr, for 2 consecutive days
Cardiff count to ten:10 or more in12hrs
Problem - poor sensitivity
5% of patients report decreased fetal activity
~ 80% of fetal movements are detected by the
mother

Factors affecting maternal assessment

Placental location.
Length of fetal movement.
Amniotic fluid volume.
Fetal anomalies.
Medications.
Obesity.

Development of Fetal biophysical

activities

Fetal biophysical activity that appears

earliest in development disappears last
with fetal hypoxia
(Gradual hypoxia theory)
Fetal tone center begin to function at
7.5-8.5 wks of gestation.
Fetal movement center at 9wks.
Fetal breathing movement become
regular at ~20-21wks.
FHR control become functional at last.

Contd

The most oxygen sensitive center is

cardiorespiratory center ,then
center for fetal movement & center
for fetal tone is affected finaly.
Hypoxia decreased fetal urine
production oligohydramnios.

FETAL HEART PATTERNS

Baseline
Beat-to- beat variability
Periodic changes
-Early deceleration
-Late deceleration
-Variable deceleration

-Accelerations
-Sinusoidal pattern

Non stress test

Role - first line screening for high risk patients

Basis -acceleration of FHR in response to fetal activity,
uterine contraction or stimulationfetal well being.
Protocol - left lateral, BP (q 5-10 min)
out patient , CTG-recording
fetal movement is recorded
Interpretation
Reactive -2 FHR accelerations,15 BPM from base line
lasting 15 seconds in 20 min monitoring
Non reactive -most common cause quiet sleep state, CNS
depressant, B-blockers, chronic smoking
NR NST- (extend test for 40 min, VAS)-still NR-CST,BPP
GA-dependent--NR-NST-Early 3rd trimester

NST contd

Advantage
Cheap, simple, risk free
Additional unusual FHR pattern that indicate fetal
jeopardy ( bradycardia, persistent variable
deceleration, sinusoidal pattern..)
Perinatal mortality: 6.2 / 1000
False positive rate - 50%
False negative rate 3.2 %

Contraction stress test

Principle
the response of the fetus at risk for uteroplacental
insufficiency to uterine contraction
In hypoxic fetus uterine contractions will elicit fetal late
decelaration
Late decelarations correlate with stillbirth, IUGR, and low
APGAR scores
Types -oxytocin(90 min)
nipple stimulation(30 min)

CST contd

How to perform the CST

External monitoring for contraction and FHR
measurement in labour & delivery suit
Patient is in semi- fowler position or left lateral
tilt
Protocol for oxytocin infusion or breast
stimulation
Goal: three contractions in ten minutes

CST contd

1.
2.
3.
4.
5.

Interpretation of CST
Negative - no late deceleration and adequate
FHR recording
Positive - late deceleration that are consistent
/ persistent in >50% of contractions
Suspicious - late deceleration are present with
less than half of the contractions
Hyperstimulation - >5 contractions in 10 min or
lasting for 90 seconds
Unsatisfactory - quality of tracing inadequate for
interpretation or no adequate contraction

CST contd

Variable deceleration: consider oligohydramnios

or cord entrapment
Loss of variability and blunting of deceleration:
ominous sign
Sinusoidal pattern: fetal anemia or feto-maternal
hemorrhage

CST contd

Management of CST
Suspicious, hyperstimulation, or unsatisfactoryrepeat after 24 hrs
Negative test repeated weekly
Positive test acted on according to clinical
condition
Advantage- not affected by alcohol or drug
ingestion by the mother, not GA dependent
Disadvantage - expensive , cxns, time
consuming, False +ve ( 50%)

CST contd

Contra indications
PROM
Multiple gestation
Cervical incompetence
Previous classical c / d or ux surgery
Placenta previa
Perinatal mortality 1.2 / 1000
High equivocal rate
False positive rate: 8 57%
False negative rate: 0.4 / 1000

Biophysical profile

Manning-introduced in 1980 : to False +vity by

using multiple variables of fetal well being

The more complete the examination of the fetus

its activities & its environment, the more accurate
may be differentiation of the healthy /diseased.

Standard BPP -a real time U/S assessment of

fetal biophysical variables - FT, GBM, FBM,&AFI
with/without NST performed for at least 30 min.

BPP...
It comprises of:

Acute variables-subject to immediate

change in response to acute
perturbations.

Chronic variables- needs long

durations(~2wks).

BPP...

Acute variables:
NST.
Fetal breathing movement-1 or more
episodes of fetal breathing movement of
30or more within 30.
Fetal movement- 3 or more discrete
body/limb movement within 30.
Fetal tone- 1 or more episodes of
extension of extremity with return to
flexion.

BPP...

Chronic variable:
Amniotic fluid volume- SDP>2cm.
Regardless of the score ,SDP<2cm needs
further evaluation.

Each of this is given a score of 0 or 2.

BPP...

Interpretation:
10/10 or 8/10(NL AFV)-risk of fetal asphyxia
within one wk if no intervention is1/1000.
8/10(abn AFV)-risk of fetal asphyxia within
one wk if no intervention is 89/1000.
AFV equivocal ,possible fetal
asphyxia.reapet test within 24hrs(preterm).

BPP...

6/10(abn AFV )- risk of fetal

asphyxia within one wk if no
intervention is 89/1000.

0-4/10 risk of fetal asphyxia within

one wk if no intervention is 91600/1000.

BPP...
Factors

affecting test results-

Antenatal

corticosteroids

-Decrease variability, breathing & body

movement.

Use of BPS is associated with

61-76% reduction in PNM.

Modified biophysical profile

NST + AFI
FT+ FBM+GBM+AFI

INDICATIONS FOR APFS

It must be considered relative

Employed in pregnancies in which
the risk of antepartum fetal demise
is increased including:
Maternal conditions:

Hyperthyroidism
Cyanotic heart disease

Indications for APFS Contd

Chronic renal disease

Type 1 DM
Hypertension d/o

Pregnancy related complications

PIH
Decreased fetal movement
oligohydramnios/polyhydramnios.

Indications for APFS Contd

IUGR.
Post term pregnancy.
Isoimmunization.
Previous fetal demise.
Multiple gestation.

When should APFS be initiated?

Choosing appropriate point in

gestation depends on: Prognosis

for neonatal survival.

Severity of maternal disease.
Risk of fetal death.
Potential for iatrogenic prematurity
complications resulting from false
positive results.

When APFS be initiated ?Contd

32-34wks Gestational age is

appropriate for most patients.
For those with multiple risk factors
may be initiated at 26-28wks of GA.

WHAT IS THE PROPER

FREQUENCY OF TESTING?

Depends on clinical judgement: Indication

not persistent, not be

repeated.
When condition that prompt testing
persists, test should be repeated
periodically.
When maternal medical condition is
stable,& CST- ve repeat weekly.
NST,BPP,MBPP wkly(2/wk in certain HRP)

How reassuring is a normal test

result?

In most cases highly reassuring ,as

the incidence of stillbirth within one
week of normal result is very low.
The stillbirth rate ,corrected for
congenital anomalies & unpredictable
causes of demise was 1.9/1000for
NST vs 0.3/1000 for CST,0.8/1000
BPP&MBPP.
The negative predictive value of NST
is 99.8%,>99.9% for CST,BPP,MBPP.

How should one respond to an

abnormal test result?

Abnormal test result should always be

considered in the context of the
overall clinical picture (false +ve).
Any deterioration in maternal medical
condition, requires fetal evaluaton
regardless of the amount of time elapsed
since the last test.
The positive predictive value of all the
tests is low (10% NST,50% bpp,<35%
CST).

Response to abn result cont;d

Non reactive NST or abnormal MBPP
should be followed by CST/BPP.
In most cases ,a positive CST indicates
that delivery is warranted.
NR NST &+VE CST is frequently
associated with serious fetal
malformation (u/s essential).
BPP score of 6:

At term, prompts delivery.

In preterm ,repeat in 24hrs (corticosteroids
<34wks)

-BPP score of 4 delivery is

warranted but individualized

Thank U