ANTEPARTUM FETAL MONITORING Reinaldo Figueroa, MD Winthrop-University Hospital.

ANTEPARTUM FETAL ANTEPARTUM FETAL MONITORINGMONITORING

Reinaldo Figueroa, MDReinaldo Figueroa, MD

Winthrop-University HospitalWinthrop-University Hospital


• Two thirds of fetal deaths occur before Two thirds of fetal deaths occur before the onset of labor.the onset of labor.

• Many antepartum deaths occur in Many antepartum deaths occur in women at risk for uteroplacental women at risk for uteroplacental insufficiency.insufficiency.

• Ideal test: allows intervention before Ideal test: allows intervention before fetal death or damage from asphyxia.fetal death or damage from asphyxia.

• Preferable: treat disease process and Preferable: treat disease process and allow fetus to go to term.allow fetus to go to term.


• Methods for antepartum fetal Methods for antepartum fetal assessmentassessment– Fetal movement countingFetal movement counting– Assessment of uterine growthAssessment of uterine growth– Antepartum fetal heart rate testingAntepartum fetal heart rate testing– Biophysical profileBiophysical profile– Doppler velocimetryDoppler velocimetry


• Uteroplacental insufficiencyUteroplacental insufficiency– Inadequate delivery of nutritive or Inadequate delivery of nutritive or

respiratory substances to appropriate fetal respiratory substances to appropriate fetal tissues.tissues.

– Inadequate exchange within the placenta Inadequate exchange within the placenta due to decreased blood flow, decreased due to decreased blood flow, decreased surface area or increased membrane surface area or increased membrane thickness.thickness.

– Inadequate maternal delivery of nutrients or Inadequate maternal delivery of nutrients or oxygen to the placenta or to problems of oxygen to the placenta or to problems of inadequate fetal uptake.inadequate fetal uptake.


• Theoretical scheme of fetal deteriorationTheoretical scheme of fetal deterioration– Fetal well being (Nutritional compromise)Fetal well being (Nutritional compromise)– Fetal growth retardation (Marginal placental Fetal growth retardation (Marginal placental

respiratory function)respiratory function)– Fetal hypoxia with stress (Decreasing Fetal hypoxia with stress (Decreasing

respiratory function)respiratory function)– Some residual effects of intermittent hypoxia Some residual effects of intermittent hypoxia

(profound respiratory compromise)(profound respiratory compromise)– AsphyxiaAsphyxia– DeathDeath


• Conditions placing the fetus at risk for UPIConditions placing the fetus at risk for UPI– Preeclampsia, chronic hypertension,Preeclampsia, chronic hypertension,– Collagen vascular disease, diabetes mellitus, Collagen vascular disease, diabetes mellitus,

renal disease,renal disease,– Fetal or maternal anemia, blood group Fetal or maternal anemia, blood group

sensitization,sensitization,– Hyperthyroidism, thrombophilia, cyanotic heart Hyperthyroidism, thrombophilia, cyanotic heart

disease,disease,– Postdate pregnancy,Postdate pregnancy,– Fetal growth restrictionFetal growth restriction


• Fetal movement countingFetal movement counting– Maternal perception of a decrease in Maternal perception of a decrease in

fetal movements may be a sign of fetal movements may be a sign of impending fetal death.impending fetal death.

– It costs nothing.It costs nothing.– In a systematic fashion, especially in low In a systematic fashion, especially in low

risk populations, may detect risk populations, may detect unsuspected fetal jeopardy.unsuspected fetal jeopardy.


• Fetal movement countingFetal movement counting– 3 movements in 30 minutes (Sadovsky).3 movements in 30 minutes (Sadovsky).– Elapsed time to register 10 fetal Elapsed time to register 10 fetal

movements (Moore and Piacquadio).movements (Moore and Piacquadio).


• Assessment of uterine growthAssessment of uterine growth– General rule: fundal height in centimeters will General rule: fundal height in centimeters will

equal the weeks of gestation.equal the weeks of gestation.– Exceptions: maternal obesity, multiple Exceptions: maternal obesity, multiple

gestation, polyhydramnios, abnormal fetal lie, gestation, polyhydramnios, abnormal fetal lie, oligohydramnios, low fetal station, and fetal oligohydramnios, low fetal station, and fetal growth restriction.growth restriction.

– Abnormalities of fundal height should lead to Abnormalities of fundal height should lead to further investigation.further investigation.

– Accuracy: poor?Accuracy: poor?


• When to begin testingWhen to begin testing– Single factors with minimal to moderate Single factors with minimal to moderate

increased risk for antepartum fetal increased risk for antepartum fetal death: 32 weeks.death: 32 weeks.

– Highest maternal risk factors: 26 weeks.Highest maternal risk factors: 26 weeks.– When estimated fetal maturity is When estimated fetal maturity is

sufficient to expect a reasonable chance sufficient to expect a reasonable chance of survival should intervention be of survival should intervention be necessary.necessary.


• Which test to use?Which test to use?– Contraction stress testContraction stress test

•Low incidence of unexpected fetal deathLow incidence of unexpected fetal death

• Increase in time, cost and inconvenienceIncrease in time, cost and inconvenience

– Nonstress testNonstress test– Biophysical profile, modified biophysical Biophysical profile, modified biophysical

profileprofile– Doppler velocimetryDoppler velocimetry

ANTEPARTUM FETAL ANTEPARTUM FETAL MONITORINGMONITORING• Contraction stress test (CST)Contraction stress test (CST)

– Uterine contractions producing an intra-Uterine contractions producing an intra-amniotic pressure in excess of 30 mm Hg amniotic pressure in excess of 30 mm Hg create an intra-myometrial pressure that create an intra-myometrial pressure that exceeds mean intra-arterial pressure, therefore exceeds mean intra-arterial pressure, therefore temporarily halting uterine blood flow.temporarily halting uterine blood flow.

– A hypoxic fetus will manifest late A hypoxic fetus will manifest late decelerations.decelerations.

– Late decelerations correlate with stillbirth, Late decelerations correlate with stillbirth, IUGR, and low Apgar scores.IUGR, and low Apgar scores.

– Oxytocin challenge test (OCT) (Ray 1972)Oxytocin challenge test (OCT) (Ray 1972)– Breast (nipple) stimulationBreast (nipple) stimulation


• How to perform the CSTHow to perform the CST– External monitors for contraction and FHR External monitors for contraction and FHR

measurement applied.measurement applied.– Patient in semi-fowler position or left Patient in semi-fowler position or left

lateral tilt (to minimize supine lateral tilt (to minimize supine hypotension).hypotension).

– Protocol for oxytocin infusion or breast Protocol for oxytocin infusion or breast stimulation.stimulation.

– Goal: three contractions in ten minutes.Goal: three contractions in ten minutes.


• Interpretation of the CSTInterpretation of the CST– Negative: no late decelerations and Negative: no late decelerations and

adequate FHR recordingadequate FHR recording– Positive: Late decelerations present with Positive: Late decelerations present with

the majority of contractions (without the majority of contractions (without excessive uterine activity)excessive uterine activity)

– Equivocal test results: Suspicious, Equivocal test results: Suspicious, hyperstimulation, unsatisfactory.hyperstimulation, unsatisfactory.

ANTEPARTUM FETAL ANTEPARTUM FETAL MONITORINGMONITORING• Interpretation of the CSTInterpretation of the CST

– Suspicious: Late decelerations are present with Suspicious: Late decelerations are present with less than half of the contractions.less than half of the contractions.

– Hyperstimulation: Decelerations after Hyperstimulation: Decelerations after contractions lasting more than 90 seconds, or contractions lasting more than 90 seconds, or with contraction frequency greater than every with contraction frequency greater than every 2 minutes.2 minutes.

– Unsatisfactory: Cannot induce adequate Unsatisfactory: Cannot induce adequate contractions or FHR recording is of poor contractions or FHR recording is of poor quality.quality.


• Other patternsOther patterns– Variable decelerations: consider Variable decelerations: consider

oligohydramnios or cord entrapment.oligohydramnios or cord entrapment.– Loss of variability and blunting of Loss of variability and blunting of

decelerations: ominous sign.decelerations: ominous sign.– Sinusoidal pattern: ominous pattern. Fetal Sinusoidal pattern: ominous pattern. Fetal

anemia or fetal-maternal hemorrhage.anemia or fetal-maternal hemorrhage.– Nonreactive negative CST: should not Nonreactive negative CST: should not

occur, preexisting CNS abnormality?occur, preexisting CNS abnormality?


• Management of CSTManagement of CST– Negative test: repeated weeklyNegative test: repeated weekly– Positive test: acted on according to Positive test: acted on according to

clinical conditionclinical condition– Equivocal test: repeat test the next dayEquivocal test: repeat test the next day


• When to shorten the interval When to shorten the interval between testingbetween testing– Deterioration in diabetic controlDeterioration in diabetic control– Worsening hypertensionWorsening hypertension– Need to introduce antihypertensive Need to introduce antihypertensive

medicationmedication– Decreased fetal movementDecreased fetal movement


• Contraindications to CSTContraindications to CST– PROMPROM– Previous classical cesarean deliveryPrevious classical cesarean delivery– Placenta previaPlacenta previa– Incompetent cervixIncompetent cervix– History of premature labor in this History of premature labor in this

pregnancypregnancy– Multiple gestationMultiple gestation


• Contraction stress testContraction stress test– Corrected perinatal mortality rate: 1.2 / Corrected perinatal mortality rate: 1.2 /

10001000– High equivocal rateHigh equivocal rate– False positive rate: 8 to 57%False positive rate: 8 to 57%– False negative rate: 0.4 / 1000False negative rate: 0.4 / 1000


• Nonstress test (NST)Nonstress test (NST)– Healthy fetuses display normal oscillations and Healthy fetuses display normal oscillations and

fluctuations of the baseline FHR (Hammacher, fluctuations of the baseline FHR (Hammacher, 1966; Kubli, 1969).1966; Kubli, 1969).

– Absence of these patterns was associated with Absence of these patterns was associated with increase in neonatal depression and perinatal increase in neonatal depression and perinatal mortality.mortality.

– Accelerations of the FHR during stress testing Accelerations of the FHR during stress testing correlated with fetal well being (Trierweiler, correlated with fetal well being (Trierweiler, 1976).1976).


• Nonstress test (NST)Nonstress test (NST)– Accelerations of the FHR occur with fetal Accelerations of the FHR occur with fetal

movement, uterine contractions, or in movement, uterine contractions, or in response to external stimuli.response to external stimuli.

– FHR accelerations appear to be a FHR accelerations appear to be a reflection of CNS alertness and activity.reflection of CNS alertness and activity.

– Absence of FHR accelerations seems to Absence of FHR accelerations seems to depict CNS depression caused by depict CNS depression caused by hypoxia, drugs, fetal sleep, or congenital hypoxia, drugs, fetal sleep, or congenital anomalies. anomalies.


• Nonstress test (NST)Nonstress test (NST)– The endpoint of the NST is the presence or absence The endpoint of the NST is the presence or absence

of FHR accelerations within a specified period of of FHR accelerations within a specified period of time.time.

– Most clinicians use 2 accelerations of 15 beats per Most clinicians use 2 accelerations of 15 beats per minute (BPM) for 15 seconds in a 20-minute period.minute (BPM) for 15 seconds in a 20-minute period.

– A healthy fetus < 32 weeks’ gestation may not have A healthy fetus < 32 weeks’ gestation may not have the reactivity or the accelerations that meet the the reactivity or the accelerations that meet the criteria of 15 BPM for 15 seconds.criteria of 15 BPM for 15 seconds.

– The more remote from term, the more likely that The more remote from term, the more likely that nonreactivity will be due to fetal prematurity.nonreactivity will be due to fetal prematurity.


• Performing the NSTPerforming the NST– External monitors for contraction and External monitors for contraction and

FHR measurement applied.FHR measurement applied.– Patient in semi-fowler position or left Patient in semi-fowler position or left

lateral tilt (to minimize supine lateral tilt (to minimize supine hypotension).hypotension).

– Fetal movement is recorded.Fetal movement is recorded.


• Interpreting the NSTInterpreting the NST– Reactive: 2 or more accelerations in 20 Reactive: 2 or more accelerations in 20

minutes.minutes.•Accelerations: an increase of at least 15 BPM Accelerations: an increase of at least 15 BPM

above the baseline lasting at least 15 above the baseline lasting at least 15 seconds.seconds.

– Fetal sound stimulation may be used to Fetal sound stimulation may be used to elicit a response.elicit a response.


• Interpreting the NSTInterpreting the NST– Non reactive: Less than 2 accelerations in a 20-Non reactive: Less than 2 accelerations in a 20-

minute period.minute period.• May extend the testing period to 40 minutes or May extend the testing period to 40 minutes or

perform a back-up test.perform a back-up test.

– There is no universal agreement on the There is no universal agreement on the number of accelerations required to consider number of accelerations required to consider the test reactive.the test reactive.

– Reactive/Nonreactive with decelerations: Reactive/Nonreactive with decelerations: individualize managementindividualize management


• Nonstress testNonstress test– Perinatal mortality: 6.2/1000Perinatal mortality: 6.2/1000– False positive rate: 50%False positive rate: 50%– False negative rate: 3.2 / 1000False negative rate: 3.2 / 1000


• Biophysical profile (BPP)Biophysical profile (BPP)– Described by Manning (1980)Described by Manning (1980)– The number of biophysical activities that The number of biophysical activities that

could be recorded increased with real could be recorded increased with real time ultrasound: time ultrasound: •Fetal movement (FM)Fetal movement (FM)•Fetal tone (FT)Fetal tone (FT)•Fetal breathing movements (FB)Fetal breathing movements (FB)•Amniotic fluid volume (AFV)Amniotic fluid volume (AFV)


• Biophysical profile (BPP) – variablesBiophysical profile (BPP) – variables– NST: reactive – as described earlier.NST: reactive – as described earlier.– FBM: present - at least 1 episode of at least 30 FBM: present - at least 1 episode of at least 30

seconds duration (within a 30 minute period).seconds duration (within a 30 minute period).– FM: present - at least 3 discrete episodes.FM: present - at least 3 discrete episodes.– FT: normal - at least 1 episode of extension of FT: normal - at least 1 episode of extension of

extremities or spine with return to flexion.extremities or spine with return to flexion.– AFV: normal – largest pocket of fluid greater AFV: normal – largest pocket of fluid greater

than 1 cm in vertical diameter.than 1 cm in vertical diameter.


• Biophysical profile (BPP)Biophysical profile (BPP)– Each variable Each variable

•When normal: 2When normal: 2

•When abnormal: 0When abnormal: 0

– Highest Score: 10, Lowest Score: 0Highest Score: 10, Lowest Score: 0– Accuracy improved by increasing the Accuracy improved by increasing the

number of variables assessed.number of variables assessed.– Overall false negative rate: 0.6/1000Overall false negative rate: 0.6/1000


• Biophysical profile (BPP)Biophysical profile (BPP)– Acute markers of fetal compromise: Acute markers of fetal compromise:

NST, FT, FBM, FMNST, FT, FBM, FM– Chronic marker of fetal compromise: Chronic marker of fetal compromise:

AFVAFV– Nervous impulses that initiate fetal Nervous impulses that initiate fetal

biophysical activities arise from different biophysical activities arise from different anatomic sites within the brain.anatomic sites within the brain.


• Biophysical profile (BPP)Biophysical profile (BPP)– Activities that become active first in Activities that become active first in

fetal development (fetal development (FTFT, , FMFM) are the last ) are the last to disappear when asphyxia arrests all to disappear when asphyxia arrests all activities.activities.

– Activities that become active later in Activities that become active later in gestation (gestation (NSTNST,,FBMFBM) will be abolished ) will be abolished 11stst in cases of hypoxia and acidosis. in cases of hypoxia and acidosis.


• Biophysical profile (BPP)Biophysical profile (BPP)– Fetal tone: 7.5 to 8.5 weeksFetal tone: 7.5 to 8.5 weeks– Fetal movement: 9 weeksFetal movement: 9 weeks– Fetal breathing: 20 to 21 weeksFetal breathing: 20 to 21 weeks– NST: 24 to 28 weeksNST: 24 to 28 weeks


• Biophysical profile (BPP)Biophysical profile (BPP)– When hypoxia and acidosisWhen hypoxia and acidosis

• Late decelerations appear (CST)Late decelerations appear (CST)

• Accelerations disappear (CST, NST, BPP)Accelerations disappear (CST, NST, BPP)

• Fetal breathing stops (BPP)Fetal breathing stops (BPP)

• Fetal movement ceases (BPP, FMC)Fetal movement ceases (BPP, FMC)

• Fetal tone absent (BPP)Fetal tone absent (BPP)

– Assessment of fetal well-being in high risk Assessment of fetal well-being in high risk pregnanciespregnancies• Reduced perinatal mortality rate from 65/1000 to Reduced perinatal mortality rate from 65/1000 to

5/1000 5/1000


• BPP and perinatal mortality (PNMR)BPP and perinatal mortality (PNMR)– 12,000 pregnancies (Manning, 1985)12,000 pregnancies (Manning, 1985)– BPP Score Corrected PNMRBPP Score Corrected PNMR

•8-10 0.68-10 0.6

•6 0.06 0.0

•4 22.04 22.0

•2 42.62 42.6

•0 187.00 187.0


• BPP and perinatal morbidityBPP and perinatal morbidity– Significant inverse linear correlation Significant inverse linear correlation

(Manning, 1990)(Manning, 1990)•Fetal distressFetal distress

•NICU admissionNICU admission

• IUGRIUGR

•5 min Apgar <75 min Apgar <7

•Cord artery pH <7.20Cord artery pH <7.20


• BPP without NSTBPP without NST– When the FM, FBM, FT, and AFV were normal When the FM, FBM, FT, and AFV were normal

(BPP 8/8), the probability of a nonreactive NST (BPP 8/8), the probability of a nonreactive NST was exceedingly small (Manning, 1987)was exceedingly small (Manning, 1987)

– The addition of NST did not improve prediction The addition of NST did not improve prediction of outcome.of outcome.

– BPP corrected PNMR false negative rateBPP corrected PNMR false negative rate• 8/8 1.43 / 1000 0.73 / 10008/8 1.43 / 1000 0.73 / 1000• 10/10 1.9 / 1000 0.65 / 100010/10 1.9 / 1000 0.65 / 1000

– Selective use of NST saves time: only 2.7% Selective use of NST saves time: only 2.7% patients need itpatients need it


• Biophysical profile (BPP)Biophysical profile (BPP)– Normal variables are highly predictive of a Normal variables are highly predictive of a

good neonatal outcome (Vintzileos, 1983).good neonatal outcome (Vintzileos, 1983).– Each abnormal variable was associated with a Each abnormal variable was associated with a

high false positive ratehigh false positive rate– Variables Best predictor ofVariables Best predictor of

• Absence of FM abnormal FHR in labor (80%)Absence of FM abnormal FHR in labor (80%)

• NR NST meconium (33%)NR NST meconium (33%)

• Decreased AFV fetal distress (37.5%)Decreased AFV fetal distress (37.5%)

• Poor FT perinatal death (42.8%)Poor FT perinatal death (42.8%)


• Biophysical profile (BPP)Biophysical profile (BPP)– Combinations of variables increase the Combinations of variables increase the

specificity of the testing, and increase specificity of the testing, and increase the ability to predict the fetus in the ability to predict the fetus in jeopardy (Vintzileos, 1983)jeopardy (Vintzileos, 1983)•NR NST, BPP 6-7: fetal distress (20%)NR NST, BPP 6-7: fetal distress (20%)

•NR NST, BPP 4: fetal distress (100%), NR NST, BPP 4: fetal distress (100%), deaths (0)deaths (0)

•BPP 1-3: perinatal deaths (57%)BPP 1-3: perinatal deaths (57%)


• BPP and NST in relation to fetal outcome BPP and NST in relation to fetal outcome (Vintzileos, 1983)(Vintzileos, 1983)– If reactive NST, then BPP If reactive NST, then BPP >> 8 in 95% of cases. 8 in 95% of cases.– If BPP < 5, then no instances of reactive NST.If BPP < 5, then no instances of reactive NST.– If nonreactive NST, then BPP If nonreactive NST, then BPP >> 8 in 39% of 8 in 39% of

cases.cases.– All hypoxic fetuses had nonreactive NST and All hypoxic fetuses had nonreactive NST and

absent fetal breathing.absent fetal breathing.– A reactive NST was associated with good A reactive NST was associated with good

outcome in all cases.outcome in all cases.


• Errors associated with the BPPErrors associated with the BPP– Management decisions based on the score only.Management decisions based on the score only.

• Intervention based on a false positive low scoreIntervention based on a false positive low score• No intervention based on a false negative normal scoreNo intervention based on a false negative normal score

– Management based on BPP without considering Management based on BPP without considering overall clinical findings.overall clinical findings.

– Poor timing of testing.Poor timing of testing.– Not including the NST.Not including the NST.– Inexperience operators, poor technique, poor Inexperience operators, poor technique, poor

equipment.equipment.


• Biophysical profile (BPP)Biophysical profile (BPP)– When the FHR accelerates, there is When the FHR accelerates, there is

virtually always fetal movement (FM)virtually always fetal movement (FM)– If the NST is reactive, there is fetal If the NST is reactive, there is fetal

movement (FM) and tone (FT)movement (FM) and tone (FT)– If the NST is reactive, do not need the If the NST is reactive, do not need the

ultrasound parameters of the BPPultrasound parameters of the BPP– Only the AFV would add additional Only the AFV would add additional

information information


• Modified biophysical profile (BPP)Modified biophysical profile (BPP)– A standard NST is combined with an amniotic A standard NST is combined with an amniotic

fluid index (AFI)fluid index (AFI)– Negative: Reactive NST / AFI > 5.0 cmNegative: Reactive NST / AFI > 5.0 cm– If NST is nonreactive or has decelerations, or if If NST is nonreactive or has decelerations, or if

the AFI is the AFI is << 5.0 cm, then a BPP is performed. 5.0 cm, then a BPP is performed.– Negative results are repeated every 3 to 4 Negative results are repeated every 3 to 4

days.days.– If the AFI > 5.0 cm, a repeat AFI may be done If the AFI > 5.0 cm, a repeat AFI may be done

in one week. in one week.


• Primary fetal surveillancePrimary fetal surveillance– There have been no adequate prospective There have been no adequate prospective

randomized studies comparing the various randomized studies comparing the various testing modalities.testing modalities.

– The final decision regarding choice of fetal The final decision regarding choice of fetal surveillance test is most often determined by surveillance test is most often determined by institutional preference and experience.institutional preference and experience.

– All forms of fetal testing are valuable and need All forms of fetal testing are valuable and need to be interpreted cautiously with full to be interpreted cautiously with full knowledge of the specific test limitations.knowledge of the specific test limitations.


• Primary fetal surveillancePrimary fetal surveillance– NST: The most popular method NST: The most popular method

•Easy to perform, easy to interpret, has fewer Easy to perform, easy to interpret, has fewer equivocal results, has excellent patient and equivocal results, has excellent patient and physician acceptance.physician acceptance.

•BPP as a back up test.BPP as a back up test.

– BPP: BPP: •Can identify oligohydramnios and anomalous Can identify oligohydramnios and anomalous

babies. babies. •Antepartum death rate is less than with the Antepartum death rate is less than with the

NST. NST.


• Doppler velocimetry of the umbilical arteriesDoppler velocimetry of the umbilical arteries– 40% of combined ventricular output is directed to 40% of combined ventricular output is directed to

the placenta by umbilical arteries.the placenta by umbilical arteries.– Assessment of umbilical blood flow provides Assessment of umbilical blood flow provides

information on blood perfusion of the information on blood perfusion of the fetoplacental unit.fetoplacental unit.

– Volume of flow increases and vascular impedance Volume of flow increases and vascular impedance decreases with advancing gestational age.decreases with advancing gestational age.

– Low vascular impedance allows a continuous Low vascular impedance allows a continuous forward blood flow throughout the cardiac cycle.forward blood flow throughout the cardiac cycle.


• Doppler velocimetryDoppler velocimetry– An increase in the vascular resistance of the An increase in the vascular resistance of the

fetoplacental unit leads to a decrease in end fetoplacental unit leads to a decrease in end diastolic flow velocity or its absence in the flow diastolic flow velocity or its absence in the flow velocity waveform.velocity waveform.

– Abnormal waveforms reflect the presence of a Abnormal waveforms reflect the presence of a structural placental lesion.structural placental lesion.

– Abnormal Doppler results require specific Abnormal Doppler results require specific management protocols and intensive fetal management protocols and intensive fetal surveillance.surveillance.


• Doppler velocimetryDoppler velocimetry– A poor indicator of fetal compromise or A poor indicator of fetal compromise or

adaptation to the placental abnormality adaptation to the placental abnormality but does identify patients at risk for but does identify patients at risk for increased perinatal mortality.increased perinatal mortality.

– Strong association between high systolic Strong association between high systolic to diastolic ratios and IUGR.to diastolic ratios and IUGR.

THANK YOUTHANK YOU

• Freeman RK, Garite TJ, Nageotte MP. Freeman RK, Garite TJ, Nageotte MP. Fetal heart rate monitoring. 3Fetal heart rate monitoring. 3rdrd edition, 2003.edition, 2003.

• Manning FA. Fetal medicine: Manning FA. Fetal medicine: principles and practice. 1995.principles and practice. 1995.

• Parer JT. Handbook of fetal heart rate Parer JT. Handbook of fetal heart rate monitoring. 2monitoring. 2ndnd edition, 1997. edition, 1997.

ANTEPARTUM FETAL MONITORING Reinaldo Figueroa, MD Winthrop-University Hospital.

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Transcript of ANTEPARTUM FETAL MONITORING Reinaldo Figueroa, MD Winthrop-University Hospital.