ASSESSMENT OF Fetal Well-being Lectures 3. Assessment of fetal well-being The major expected outcome...

ASSESSMENT OF ASSESSMENT OF Fetal Fetal

Well-beingWell-beingLectures Lectures 33

Assessment of fetal well-Assessment of fetal well-beingbeing

• The major expected outcome is the detection of The major expected outcome is the detection of potential fetal compromisepotential fetal compromise

• Used before intrauterine asphyxia of the fetus Used before intrauterine asphyxia of the fetus and health care provider can take measures to and health care provider can take measures to prevent or minimize adverse perinatal outcomesprevent or minimize adverse perinatal outcomes

• First- and second-trimester antepartal assessment is directed primarily at the diagnosis of fetal anomalies.

• The goal of third-trimester testing is to determine whether the intrauterine environment continues to be supportive to the fetus.

Daily Fetal Daily Fetal Movement Movement

CountsCounts

Daily Fetal Daily Fetal Movement Movement

CountsCounts

Daily Fetal Movement Daily Fetal Movement Counts Counts Kick CountsKick Counts

– Assessment of fetal activity by the motherAssessment of fetal activity by the mother– Non-invasive, inexpensive, simple to Non-invasive, inexpensive, simple to

understand, and does not interfere with routine understand, and does not interfere with routine at homeat home

– once a dayonce a day,, roughly at the same time every roughly at the same time every day day in a comfortable sitting or lying positionin a comfortable sitting or lying position

– when baby is usually activewhen baby is usually active ( (after meals, after after meals, after activity, and in the eveningactivity, and in the evening)). .

– Since healthy babies have sleep cycles, baby Since healthy babies have sleep cycles, baby may not kick, or kick less than usual, or have may not kick, or kick less than usual, or have less than 10 kicks in 2 hours. If so, wake up the less than 10 kicks in 2 hours. If so, wake up the baby by drinking fluid or by walking for 5 baby by drinking fluid or by walking for 5 minutes. minutes. Repeat the kick countRepeat the kick count. .

Daily Fetal Movement Counts Daily Fetal Movement Counts Kick Kick CountsCounts

–No less than3 movements in 30 minutes No less than3 movements in 30 minutes

–Most healthy babies should take less than 2 hours for 10 kicks. Most healthy babies should take less than 2 hours for 10 kicks.

–not moved 10 times in 2 hours or the baby has sustained significant not moved 10 times in 2 hours or the baby has sustained significant changes. changes.

–Fetal alarm signal Fetal alarm signal if no movement in 12 hoursif no movement in 12 hours

–The evaluation may include: The evaluation may include: –UltrasoundUltrasound - taking pictures from sound waves to evaluate the - taking pictures from sound waves to evaluate the growth of the baby, amniotic fluid quantity, placenta, blood flow growth of the baby, amniotic fluid quantity, placenta, blood flow pattern etc. pattern etc.

–Non stress test (NST)Non stress test (NST) -Baby's heart rate monitoring in -Baby's heart rate monitoring in response to its own movements response to its own movements

–Biophysical profile (BPP)Biophysical profile (BPP) -using an ultrasound exam with a -using an ultrasound exam with a non stress test (NST) to evaluate baby's heart rate, breathing, non stress test (NST) to evaluate baby's heart rate, breathing, body movement, muscle tone, and amniotic fluid quantity body movement, muscle tone, and amniotic fluid quantity

–Contraction stress test (CST)Contraction stress test (CST) -Baby's heart rate monitoring in -Baby's heart rate monitoring in response to uterine contractions response to uterine contractions

OBSTETRICOBSTETRICULTRASOUNDULTRASOUNDOBSTETRICOBSTETRIC

ULTRASOUNDULTRASOUND

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• Ultrasound in obstetrics can provide Ultrasound in obstetrics can provide good good information about the fetus information about the fetus and its and its environment environment

• With ultrasound, can be determined an With ultrasound, can be determined an early intervention early intervention or or conservative conservative managementmanagement in pregnancy in pregnancy

• Latest developments in ultrasound Latest developments in ultrasound

examination is a transvaginal examination is a transvaginal ultrasound discovery - the observation ultrasound discovery - the observation of "FLOW DOPLLER" and the most of "FLOW DOPLLER" and the most sophisticated ultrasound 3 D and 4D sophisticated ultrasound 3 D and 4D which has a high ability to determine which has a high ability to determine fetal conditionfetal condition

• Ultrasound in obstetrics can provide Ultrasound in obstetrics can provide good good information about the fetus information about the fetus and its and its environment environment

• With ultrasound, can be determined an With ultrasound, can be determined an early intervention early intervention or or conservative conservative managementmanagement in pregnancy in pregnancy

• Latest developments in ultrasound Latest developments in ultrasound

examination is a transvaginal examination is a transvaginal ultrasound discovery - the observation ultrasound discovery - the observation of "FLOW DOPLLER" and the most of "FLOW DOPLLER" and the most sophisticated ultrasound 3 D and 4D sophisticated ultrasound 3 D and 4D which has a high ability to determine which has a high ability to determine fetal conditionfetal condition

UltrasonographyUltrasonography• Indications for useIndications for use

– Fetal heart rate activityFetal heart rate activity– Gestational ageGestational age– Fetal growthFetal growth– Fetal anatomyFetal anatomy– Fetal genetic disorders and physical Fetal genetic disorders and physical

anomaliesanomalies– Placental position and functionPlacental position and function– visual assistance to other invasive testsvisual assistance to other invasive tests– Fetal well-beingFetal well-being

UltrasonographyUltrasonography

AbdominalAbdominal • After 1 trimester After 1 trimester • Full bladerFull blader

VaginalVaginal• 1 trimester1 trimester• Early diagnostic of uterine Early diagnostic of uterine

pregnancy pregnancy • Empty blader Empty blader • Obese womanObese woman

UltrasonographyUltrasonography

An important and safe technique in An important and safe technique in antepartum fetal surveillance antepartum fetal surveillance Levels of ultrasonography:Levels of ultrasonography:

• Standard examinationStandard examination– Used for specific indications, i.e., fetal viability, fetal Used for specific indications, i.e., fetal viability, fetal

presentation, gestational age, locate the placenta, presentation, gestational age, locate the placenta, fetal anatomy and malformationfetal anatomy and malformation

• Specialized or targeted examinationSpecialized or targeted examination– Suspicion of an abnormal fetus (abnormal finding on Suspicion of an abnormal fetus (abnormal finding on

clinical examination, poly- or oligohydramnionios, clinical examination, poly- or oligohydramnionios, elevated AFP)elevated AFP)

Ultrasonography: Ultrasonography: Indication for use 1 Indication for use 1

trimestertrimester• Number, size, location of gestational sacNumber, size, location of gestational sac• Fetal cardiac and body movementFetal cardiac and body movement• Uterine abnormalities (bicornuate Uterine abnormalities (bicornuate

uterus, uterine fibroid, IUD) or adnexal uterus, uterine fibroid, IUD) or adnexal massesmasses

• Duration of pregnancy (crown-rump Duration of pregnancy (crown-rump length)length)

• Visualization during chorionic villus Visualization during chorionic villus samplingsampling

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Ultrasonography: Ultrasonography: Indication for use Indication for use

( 2( 2ndnd and 3 and 3rdrd trimester ) trimester )1.1. Fetal viability, number and presentation, Fetal viability, number and presentation, 2.2. Establishment of fetal age and growth by fetal biometry Establishment of fetal age and growth by fetal biometry

including:including:a.a. BPD ~ biparietal diameterBPD ~ biparietal diameterb.b. FL ~ femur lengthFL ~ femur lengthc.c. AC ~ Abdominal circumferenceAC ~ Abdominal circumferenced.d. Biophysical profileBiophysical profile

3.3. Evaluation of fetal anatomic structures: Evaluation of fetal anatomic structures: a.a. Cerebral lateral ventriclesCerebral lateral ventriclesb.b. Spine Spine c.c. Four chamber view of the heartFour chamber view of the heartd.d. Stomach-bowel,Stomach-bowel, abdominal wall at the area of the umbilical cord abdominal wall at the area of the umbilical cord

insertioninsertione.e. Bladder and kidneyBladder and kidneyf.f. Limbs and umbilical cordLimbs and umbilical cord

4.4. Amount of amniotic fluid Amount of amniotic fluid 5.5. Placental localization and maturityPlacental localization and maturity6.6. Evaluation of the uterine, and adnexae for abnormalities Evaluation of the uterine, and adnexae for abnormalities

and massesand masses7.7. Cervical lengthCervical length8.8. Visual assistance to invasive testsVisual assistance to invasive tests

1.1. Fetal viability, number and presentation, Fetal viability, number and presentation, 2.2. Establishment of fetal age and growth by fetal biometry Establishment of fetal age and growth by fetal biometry

including:including:a.a. BPD ~ biparietal diameterBPD ~ biparietal diameterb.b. FL ~ femur lengthFL ~ femur lengthc.c. AC ~ Abdominal circumferenceAC ~ Abdominal circumferenced.d. Biophysical profileBiophysical profile

3.3. Evaluation of fetal anatomic structures: Evaluation of fetal anatomic structures: a.a. Cerebral lateral ventriclesCerebral lateral ventriclesb.b. Spine Spine c.c. Four chamber view of the heartFour chamber view of the heartd.d. Stomach-bowel,Stomach-bowel, abdominal wall at the area of the umbilical cord abdominal wall at the area of the umbilical cord

insertioninsertione.e. Bladder and kidneyBladder and kidneyf.f. Limbs and umbilical cordLimbs and umbilical cord

4.4. Amount of amniotic fluid Amount of amniotic fluid 5.5. Placental localization and maturityPlacental localization and maturity6.6. Evaluation of the uterine, and adnexae for abnormalities Evaluation of the uterine, and adnexae for abnormalities

and massesand masses7.7. Cervical lengthCervical length8.8. Visual assistance to invasive testsVisual assistance to invasive tests

Fetal heart activityFetal heart activity

• 6-7 weeks by echo scaner6-7 weeks by echo scaner• 10-12 weeks by Doopler10-12 weeks by Doopler

Fetal viabilityFetal viability • Fetal cardiac activityFetal cardiac activity• Fetal movementFetal movement• Breathing movementBreathing movement

Gestational ageGestational age• Gestational sac dimensions (about 8 weeks)Gestational sac dimensions (about 8 weeks)• Crown-rump length (7-12 weeks)Crown-rump length (7-12 weeks)• Biparietal diameter (after 12 weeks)Biparietal diameter (after 12 weeks)• Femur length (after 12 weeks)Femur length (after 12 weeks)

• BPD, FL and AC the most important BPD, FL and AC the most important parameters for determination of gestational parameters for determination of gestational age age

• Determination of gestational age should be Determination of gestational age should be performed prior to 26 weeks gestational age performed prior to 26 weeks gestational age

• 33rdrd trimester determination of gestational trimester determination of gestational age does not acurately reflect gestational age does not acurately reflect gestational ageage

Fetal growthFetal growth• BPD ~ biparietal diameterBPD ~ biparietal diameter • FL ~ femur lengthFL ~ femur length• AC ~ Abdominal circumferenceAC ~ Abdominal circumference

• Discrepancy resulting from inaccurate datesDiscrepancy resulting from inaccurate dates – True intrauterine growth restriction (IUGR)True intrauterine growth restriction (IUGR)

• Symmetric - Symmetric - the fetus being small in all parameters, reflects a chronic or long-standing insult and may be caused by low genetic growth potential, intrauterine infection, undernutrition, heavy smoking, or chromosomal aberration.

• Asymmetric - Asymmetric - head and body growth varying, suggests an acute or late-occurring deprivation, such as placental insufficiency resulting from hypertension, renal disease, or cardiovascular disease.

– Macrosomia -Macrosomia - weighing more than 4000 g, associated with maternal glucose intolerance, carries an increased risk of intrauterine fetal death, and at increased risk for trauma during birth.

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Ultrasonography:Ultrasonography: gestational gestational ageage

Week’s GestationWeek’s Gestation

7 – 10 7 – 10 10 - 1410 - 14 15 - 2815 - 28 2929Crown-rump Crown-rump length (CRL)length (CRL)

Crown-rump Crown-rump lengthlength

Biparietal Biparietal Diameter (BPD)Diameter (BPD)

Femur Length Femur Length (FL)(FL)

Humerus Length Humerus Length (HL)(HL)

Biparietal Biparietal DiameterDiameter

Femur LengthFemur Length

Humerus LengthHumerus Length

Head Head Circumference Circumference (HC)(HC)

Binocular Binocular distancedistance

Femur LengthFemur Length

Humerus LengthHumerus Length

Binocular Binocular distance distance Biparietal Biparietal DiameterDiameter

Other long bonesOther long bones

Head Head CircumferenceCircumference

a In decreasing orderb Only if cephalic index ( BPD divided by occipital-frontal diameter ) is

normal ( 76-84%) ; otherwise , the fetal head may be dolichocephalic or brachycephalic

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1st trimester fetus CRL

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28 mm CRL in 10 weeks twin pregnancy

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Biparietal Diameter

a cross section through the fetal head at the level of the thalamus. The skull is represented by the thick white lines which surround the brain. This view is used to measure the biparietal diameter (line) and the circumference of the head (dots).

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Fetal Femur

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Pregnant uterus - longitudinal

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Fetal : intracranial structure and extremity

FetalFetal anatomyanatomy

• Head (ventricles, blood Head (ventricles, blood vessels)vessels)

• NeckNeck• SpineSpine• HeartHeart• StomachStomach

• Small Small bowelbowel

• LiverLiver• KidneyKidney• Blader Blader • LimbLimb

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Fetal CardiacStructure

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Fetal Liver andLung interface

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Fetal Liver3rd Trimester

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Fetal Spine

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SpineSpine3 D3 D

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Neural tube defectsNeural tube defects

• NTD’s result from failure of tube NTD’s result from failure of tube closure by the 6closure by the 6thth weeks gestational weeks gestational age (embryonic age 26 – 28 days )age (embryonic age 26 – 28 days )

• Various NTD’s anomalies :Various NTD’s anomalies :– AnencephalyAnencephaly– EncephaloceleEncephalocele– Spina BifidaSpina Bifida

• NTD’s result from failure of tube NTD’s result from failure of tube closure by the 6closure by the 6thth weeks gestational weeks gestational age (embryonic age 26 – 28 days )age (embryonic age 26 – 28 days )

• Various NTD’s anomalies :Various NTD’s anomalies :– AnencephalyAnencephaly– EncephaloceleEncephalocele– Spina BifidaSpina Bifida

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Gross malformation may be detected Gross malformation may be detected in 1in 1stst trimester sonogram 1: trimester sonogram 1:

Gross malformation may be detected Gross malformation may be detected in 1in 1stst trimester sonogram 1: trimester sonogram 1:

• Anencephalus (Anencephalus (absence absence of a major portion of the of a major portion of the brain, skull, and scalpbrain, skull, and scalp))

• Acrania (Acrania (partial or partial or complete absence of the complete absence of the craniumcranium)). .

• Anencephalus (Anencephalus (absence absence of a major portion of the of a major portion of the brain, skull, and scalpbrain, skull, and scalp))

• Acrania (Acrania (partial or partial or complete absence of the complete absence of the craniumcranium)). .

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Spina BifidaSpina BifidaSpina BifidaSpina Bifida

• Consist of a hiatus, usually in the Consist of a hiatus, usually in the lumbosacral vertebrae, through which a lumbosacral vertebrae, through which a meningeal sac may protruded meningeal sac may protruded → → meningocelemeningocele

• 90% of cases, the sac contains neural 90% of cases, the sac contains neural elementselements → → meningomyelocelemeningomyelocele

• The fetal spine should be examined by The fetal spine should be examined by sonography with: sonography with: sagittal, tranverse and sagittal, tranverse and coronal viewscoronal views

• Consist of a hiatus, usually in the Consist of a hiatus, usually in the lumbosacral vertebrae, through which a lumbosacral vertebrae, through which a meningeal sac may protruded meningeal sac may protruded → → meningocelemeningocele

• 90% of cases, the sac contains neural 90% of cases, the sac contains neural elementselements → → meningomyelocelemeningomyelocele

• The fetal spine should be examined by The fetal spine should be examined by sonography with: sonography with: sagittal, tranverse and sagittal, tranverse and coronal viewscoronal views

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SpinaBifida

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NEURAL TUBE DEFECTS

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NEURAL TUBE DEFECTS

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Fetal anatomyFetal anatomyGross malformation may be detected Gross malformation may be detected

in 1in 1stst trimester sonogram 2: trimester sonogram 2:

Fetal anatomyFetal anatomyGross malformation may be detected Gross malformation may be detected

in 1in 1stst trimester sonogram 2: trimester sonogram 2: • Hydrancephaly (the cerebral Hydrancephaly (the cerebral

hemispheres are absent and hemispheres are absent and replaced by sacs filled with replaced by sacs filled with cerebrospinal fluidcerebrospinal fluid

• Cystic Hygroma (is a Cystic Hygroma (is a congenital multiloculated congenital multiloculated lymphatic lesion that can arise lymphatic lesion that can arise anywhere, but is classically anywhere, but is classically found in the left posterior found in the left posterior triangle of the neck. triangle of the neck.

• Hydrancephaly (the cerebral Hydrancephaly (the cerebral hemispheres are absent and hemispheres are absent and replaced by sacs filled with replaced by sacs filled with cerebrospinal fluidcerebrospinal fluid

• Cystic Hygroma (is a Cystic Hygroma (is a congenital multiloculated congenital multiloculated lymphatic lesion that can arise lymphatic lesion that can arise anywhere, but is classically anywhere, but is classically found in the left posterior found in the left posterior triangle of the neck. triangle of the neck.

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Abdominal Wall DefectsAbdominal Wall DefectsAbdominal Wall DefectsAbdominal Wall Defects

• The two most common are :The two most common are :– OmphaloceleOmphalocele– GastroschisisGastroschisis

• Can be ascertained early in pregnancy by Can be ascertained early in pregnancy by maternal serum alphafetoprotein maternal serum alphafetoprotein screening programsscreening programs

• The two most common are :The two most common are :– OmphaloceleOmphalocele– GastroschisisGastroschisis

• Can be ascertained early in pregnancy by Can be ascertained early in pregnancy by maternal serum alphafetoprotein maternal serum alphafetoprotein screening programsscreening programs

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Gross malformation may be Gross malformation may be detected in 1detected in 1stst trimester trimester

sonogram 3: sonogram 3:


sonogram 3: sonogram 3: • Omphalocele (Omphalocele (abdominal wall abdominal wall defectdefect in which the intestines, in which the intestines, liver, and occasionally other liver, and occasionally other organs remain outside of the organs remain outside of the abdomen in a sacabdomen in a sac))

• Gastroschisis (Gastroschisis (paraomphaloceleparaomphalocele congenitalcongenital abdominal wall defect abdominal wall defect in which the intestines and in which the intestines and sometimes other organs develop sometimes other organs develop outside the fetal abdomen outside the fetal abdomen through an opening in the through an opening in the abdominal wallabdominal wall))

• Omphalocele (Omphalocele (abdominal wall abdominal wall defectdefect in which the intestines, in which the intestines, liver, and occasionally other liver, and occasionally other organs remain outside of the organs remain outside of the abdomen in a sacabdomen in a sac))

• Gastroschisis (Gastroschisis (paraomphaloceleparaomphalocele congenitalcongenital abdominal wall defect abdominal wall defect in which the intestines and in which the intestines and sometimes other organs develop sometimes other organs develop outside the fetal abdomen outside the fetal abdomen through an opening in the through an opening in the abdominal wallabdominal wall))

OMPHALOCELE

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GASTROSCHISIS

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Duodenal atresiaDuodenal atresia

• Diagnosed prenatally by the Diagnosed prenatally by the demonstration of the demonstration of the double bubble signdouble bubble sign ( distension of the stomach and first part ( distension of the stomach and first part of the duodenum ) of the duodenum )

• Must be differentiated from other cystic Must be differentiated from other cystic structures in the upper abdomenstructures in the upper abdomen

• Diagnosis generally is not possible Diagnosis generally is not possible before 24 weeksbefore 24 weeks

• 30% of cases has been associated with 30% of cases has been associated with trisomy 21 trisomy 21

• Diagnosed prenatally by the Diagnosed prenatally by the demonstration of the demonstration of the double bubble signdouble bubble sign ( distension of the stomach and first part ( distension of the stomach and first part of the duodenum ) of the duodenum )

• Must be differentiated from other cystic Must be differentiated from other cystic structures in the upper abdomenstructures in the upper abdomen

• Diagnosis generally is not possible Diagnosis generally is not possible before 24 weeksbefore 24 weeks

• 30% of cases has been associated with 30% of cases has been associated with trisomy 21 trisomy 21

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• Fused twins (Fused twins (Siamese Siamese twinstwins)) are identical twins are identical twins whose bodies are joined in whose bodies are joined in utero utero

• Fused twins (Fused twins (Siamese Siamese twinstwins)) are identical twins are identical twins whose bodies are joined in whose bodies are joined in utero utero

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Fetal genetic Disorders Fetal genetic Disorders Nuchal TranslucencyNuchal Translucency

Fetal genetic Disorders Fetal genetic Disorders Nuchal TranslucencyNuchal Translucency

• The maximum thickness of the The maximum thickness of the subcutaneus translucent area between subcutaneus translucent area between the skin and the soft tissues overlying the skin and the soft tissues overlying the posterior aspect of the cervical spine the posterior aspect of the cervical spine in sagital scane plane. (10-14 weeks)in sagital scane plane. (10-14 weeks)

• A thickness > 3 mm ( sagital plane):A thickness > 3 mm ( sagital plane):– 90% trisomy 18 and 1390% trisomy 18 and 13– 80% trisomy 2180% trisomy 21– 5% normal5% normal

• The maximum thickness of the The maximum thickness of the subcutaneus translucent area between subcutaneus translucent area between the skin and the soft tissues overlying the skin and the soft tissues overlying the posterior aspect of the cervical spine the posterior aspect of the cervical spine in sagital scane plane. (10-14 weeks)in sagital scane plane. (10-14 weeks)

• A thickness > 3 mm ( sagital plane):A thickness > 3 mm ( sagital plane):– 90% trisomy 18 and 1390% trisomy 18 and 13– 80% trisomy 2180% trisomy 21– 5% normal5% normal

Placenta position and Placenta position and functionfunction

• LocationLocation• Relationship between cervical osRelationship between cervical os• Maturation Maturation

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Uterus and Adnexa Uterus and Adnexa Uterus and Adnexa Uterus and Adnexa • Cervical incompetence :Cervical incompetence :

– Tunneling of the internal Tunneling of the internal ( dilatation )( dilatation )

– Cervical length < 3 cmCervical length < 3 cm– Bulging membranes Bulging membranes

( with or ( with or without prolaps of the cord or without prolaps of the cord or fetal parts )fetal parts )

• 30 weeks of gestational age: 30 weeks of gestational age: length of cervix more than 3 cmlength of cervix more than 3 cm

• Adnexal mass :Adnexal mass :– Physiological: Diameter corpus Physiological: Diameter corpus

luteum at pregnancy about 2 cmluteum at pregnancy about 2 cm

• Uterine fibroidUterine fibroid

• Cervical incompetence :Cervical incompetence :– Tunneling of the internal Tunneling of the internal

( dilatation )( dilatation )– Cervical length < 3 cmCervical length < 3 cm– Bulging membranes Bulging membranes

( with or ( with or without prolaps of the cord or without prolaps of the cord or fetal parts )fetal parts )

• 30 weeks of gestational age: 30 weeks of gestational age: length of cervix more than 3 cmlength of cervix more than 3 cm

• Adnexal mass :Adnexal mass :– Physiological: Diameter corpus Physiological: Diameter corpus

luteum at pregnancy about 2 cmluteum at pregnancy about 2 cm

• Uterine fibroidUterine fibroid

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Sonographic assesment of Sonographic assesment of the amniotic fluidthe amniotic fluid

Sonographic assesment of Sonographic assesment of the amniotic fluidthe amniotic fluid

• Normal : at 2Normal : at 2ndnd and 3 and 3rdrd trimester trimester vertical pocket about 2 cmvertical pocket about 2 cm

• AFI ( amniotic fluid index ): sum of AFI ( amniotic fluid index ): sum of the depth of the largest pocket of the depth of the largest pocket of fluid in the four quadrants of fluid in the four quadrants of abdomen abdomen

• AFI < 5 cm : strongly asociated with AFI < 5 cm : strongly asociated with oligohidramnions postmaturity oligohidramnions postmaturity

• Normal : at 2Normal : at 2ndnd and 3 and 3rdrd trimester trimester vertical pocket about 2 cmvertical pocket about 2 cm

• AFI ( amniotic fluid index ): sum of AFI ( amniotic fluid index ): sum of the depth of the largest pocket of the depth of the largest pocket of fluid in the four quadrants of fluid in the four quadrants of abdomen abdomen

• AFI < 5 cm : strongly asociated with AFI < 5 cm : strongly asociated with oligohidramnions postmaturity oligohidramnions postmaturity

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Amniotic FluidIndex

Interpretation of the Interpretation of the AFlAFl10.1 to 24.0 cm10.1 to 24.0 cm Normal Normal

5.1 to 10.0 cm5.1 to 10.0 cm Borderline BorderlineLess than or equal 5.0 cm Abnormal Less than or equal 5.0 cm Abnormal (Oligohydramnios)(Oligohydramnios)

Greater than 24.0 cm Greater than 24.0 cm Abnormal Abnormal ((PolyhydramniosPolyhydramnios))

Oligohydramnios is associated with congenital abnomalies (ex. renal agenesis) growth restriction fetal distress

Polyhydramnios is associated with neural tube defects obstruction of the fetal gastrointestinal tract, multiple fetuses and fetal hydrops

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DOPPLER VELOCIMETRYDOPPLER VELOCIMETRYDOPPLER VELOCIMETRYDOPPLER VELOCIMETRY

• The primary use of Doppler echo shifts in The primary use of Doppler echo shifts in obstetrics have been to detect and measured obstetrics have been to detect and measured blood flow blood flow

• Basis of Doppler Velocimetry : The sound of Basis of Doppler Velocimetry : The sound of moving blood cells within vasculature generates moving blood cells within vasculature generates an effective Doppler Shift an effective Doppler Shift

• There are 2 methods of estimating circulatory There are 2 methods of estimating circulatory hemodynamics :hemodynamics :– Direct measurement of the volume of blood Direct measurement of the volume of blood

flowflow– Indirect estimation of flow velocity using wave Indirect estimation of flow velocity using wave

form analysis form analysis

• The primary use of Doppler echo shifts in The primary use of Doppler echo shifts in obstetrics have been to detect and measured obstetrics have been to detect and measured blood flow blood flow

• Basis of Doppler Velocimetry : The sound of Basis of Doppler Velocimetry : The sound of moving blood cells within vasculature generates moving blood cells within vasculature generates an effective Doppler Shift an effective Doppler Shift

• There are 2 methods of estimating circulatory There are 2 methods of estimating circulatory hemodynamics :hemodynamics :– Direct measurement of the volume of blood Direct measurement of the volume of blood

flowflow– Indirect estimation of flow velocity using wave Indirect estimation of flow velocity using wave

form analysis form analysis

DOPPLER VELOCIMETRYDOPPLER VELOCIMETRY

• The shifted frequencies can be The shifted frequencies can be displayed as a plot of velocity versus displayed as a plot of velocity versus time, and the shape of these time, and the shape of these waveform can be analyzed to give waveform can be analyzed to give information about blood flow and information about blood flow and resistance in a given circulationresistance in a given circulation

• Velocity waveforms from umbilical Velocity waveforms from umbilical and uterine arteries, reported as and uterine arteries, reported as systolic/diastolic (S/D) ratio achievesystolic/diastolic (S/D) ratio achieve

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• Most fetuses will achieve an S/D ratios Most fetuses will achieve an S/D ratios of 3 or less by 30 weeksof 3 or less by 30 weeks

• Persistent elevation of S/D ratios after Persistent elevation of S/D ratios after 30 weeks is associated with IUGR 30 weeks is associated with IUGR resulting from uteroplacental resulting from uteroplacental insuficiencyinsuficiency

• In postterm pregnancies an elevated S/D In postterm pregnancies an elevated S/D ratio indicates a poorly perfused ratio indicates a poorly perfused placentaplacenta

• Abnormal result are seen with Abnormal result are seen with chromosome abnomalities in the fetuschromosome abnomalities in the fetus


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Fetal Umbilical Cord Doppler

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Fetal Breathing Fetal Breathing MovementMovement

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Fetal Umbilical arteryand Bladder

Biophysical profile (BPP)Biophysical profile (BPP)• Real-time ultrasound permits detailed assessment of the physical

and physiologic characteristics of the developing fetus and cataloging of normal and abnormal biophysical responses to stimuli.

• The biophysical profile (BPP) is a noninvasive dynamic assessment of a fetus and its environment by ultrasonography and external fetal monitoring. BPP scoring is a method of fetal risk surveillance based on the assessment of both acute and chronic markers of nonreassuring fetal status.

• The BPP includes:– fetal breathing movements, – fetal movements, – fetal tone, – fetal heart rate patterns by means of a nonstress test, – AFV;

• The fetal response to central hypoxia is alteration in movement, muscle tone, breathing, and heart rate patterns. The presence of normal fetal biophysical activities indicates that the central nervous system (CNS) is functional and the fetus therefore is not hypoxemic

Biophysical profile (BPP)Biophysical profile (BPP)

Biophysical profile (BPP)Biophysical profile (BPP)• The BPP is an accurate indicator of impending fetal

death. • Fetal acidosis can be diagnosed early with a nonreactive

nonstress test and absent fetal breathing movements. • An abnormal BPP score and oligohydramnios are

indications that labor should be induced.• Fetal infection in women whose membranes rupture

prematurely (at less than 37 weeks of gestation) can be diagnosed early by changes in biophysical activity that precede the clinical signs of infection and indicate the necessity for immediate birth.

• When the BPP score is normal and the risk of fetal death low, intervention is indicated only for obstetric or maternal factors.

Magnetic Magnetic resonance resonance imagingimaging

Magnetic Magnetic resonance resonance imagingimaging

Magnetic resonance Magnetic resonance imaging (MRI)imaging (MRI)

• Noninvasive radiologic techniqueNoninvasive radiologic technique• Like CT provides pictures of soft Like CT provides pictures of soft

tissuetissue• Unlike CT is not use ionizing Unlike CT is not use ionizing

radiationradiation

– Fetal structureFetal structure– Placenta (position, density, and presence Placenta (position, density, and presence

of gestational trophoblastic disease) of gestational trophoblastic disease) – Quantity of amniotic fluidQuantity of amniotic fluid– Maternal structures (uterus, cervix, Maternal structures (uterus, cervix,

adnexa, adnexa, and pelvis)and pelvis)

– Biochemical status of tissues and organsBiochemical status of tissues and organs– Soft tissue, metabolic, or functional Soft tissue, metabolic, or functional

anomaliesanomalies

Magnetic resonance Magnetic resonance imaging (MRI)imaging (MRI)

BIOCHEMICAL BIOCHEMICAL ASSESSMENTASSESSMENTBIOCHEMICAL BIOCHEMICAL ASSESSMENTASSESSMENT

BIOCHEMICAL BIOCHEMICAL ASSESSMENTASSESSMENT

• Involves biological examination and Involves biological examination and chemical determinationchemical determination

• Procedures used to obtain needed Procedures used to obtain needed speciment speciment – AmniocentesisAmniocentesis– Percutaneous umbilical blood samplingPercutaneous umbilical blood sampling– Chorionic villus samplingChorionic villus sampling– Maternal samplingMaternal sampling

BIOCHEMICAL BIOCHEMICAL ASSESSMENT.ASSESSMENT.

AmniocentesisAmniocentesis

BIOCHEMICAL BIOCHEMICAL ASSESSMENT.ASSESSMENT.



• First introduced by Serr and First introduced by Serr and Fuchs and Riis in the 1950s for Fuchs and Riis in the 1950s for fetal sex determinationfetal sex determination

• Only at the late 70Only at the late 70thth a static a static ultrasound was used to locate ultrasound was used to locate the placenta and amniotic fluid the placenta and amniotic fluid pocketpocket

• Only In 1983, Jeanty reported a Only In 1983, Jeanty reported a technique of amniocentesis technique of amniocentesis ’’under ultrasound vision’’’’under ultrasound vision’’

Amniocentesis is perform to obtain amniotic fluid, Amniocentesis is perform to obtain amniotic fluid, which contains fetal cells. Under direct which contains fetal cells. Under direct ultrasonographic visualization, a needle is inserted ultrasonographic visualization, a needle is inserted transabdominally into the uterus, amniotic fluid is transabdominally into the uterus, amniotic fluid is withdraw into a syringe, and the various withdraw into a syringe, and the various assessment are performedassessment are performed

Amniocentesis: Amniocentesis: IndicationsIndications• Genetic disordersGenetic disorders

– women more than 35 years old, with a previous child with a chromosomal abnormality, or with a family history of chromosomal anomalies.

– Inherited errors of metabolism (such as Tay-Sachs disease, hemophilia, and thalassemia) and other disorders for which marker genes are known may also be detected.

– Cells are cultured for karyotyping of chromosomes. Karyotyping also permits determination of fetal sex, which is important if a sexlmked disorder is suspected.

– Alpha-fetoprotein (AFP) levels are assessed as a followup for elevated levels in maternal serum. High AFP levels in amniotic fluid help confirm the diagnosis of a neural tube defect such as spina bifida or anencephaly or an abdominal wall defect such as omphalocele. AFP levels may also be elevated in a normal multifetal pregnancy and with intestinal atresia, presumably caused by lack of fetal swallowing.

• Assessment of pulmonary maturity Assessment of pulmonary maturity – L/S > 2:1L/S > 2:1

• Diagnosis of fetal hemolytic disesaseDiagnosis of fetal hemolytic disesase– bilirubin level < 0.015bilirubin level < 0.015


• After 10-14 weeks gestationAfter 10-14 weeks gestation– Early – earlier than 15 weeks Early – earlier than 15 weeks – Late – second trimester after 15 weeksLate – second trimester after 15 weeks

• Only the amniotic (inner) sac should Only the amniotic (inner) sac should be aspiratedbe aspirated

• Approximately 1 cc for gestational Approximately 1 cc for gestational ageage

• laboratory failure op to 20%laboratory failure op to 20%

ComplicationsComplications

• Leakage of amniotic fluid (better Leakage of amniotic fluid (better prognosis than spontaneous leakage)prognosis than spontaneous leakage)

• AmnionitisAmnionitis• Vaginal bleedingVaginal bleeding• Needle puncture of the fetusNeedle puncture of the fetus• Long term complications:Long term complications:

– Respiratory distress??Respiratory distress??– Isoimmunization??Isoimmunization??

AmniocentesisAmniocentesis• Maternal Maternal

complicationscomplications– HemorrhageHemorrhage– Fetomaternal Fetomaternal

hemorrhage with hemorrhage with possible maternal Rh possible maternal Rh isoimmunizationisoimmunization

– InfectionInfection– LaborLabor– Abruptio placentaeAbruptio placentae– Damage to intestines or Damage to intestines or

bladderbladder– Amniotic fluid embolismAmniotic fluid embolism

• Fetal Fetal complicationscomplications– DeathDeath– HemorrhageHemorrhage– Infection Infection

(amnionitis)(amnionitis)– Direct injury from Direct injury from

the needlethe needle– Miscarriage or Miscarriage or

preterm laborpreterm labor– Leakage of amniotic Leakage of amniotic

fluidfluid

Amniocentesis and HIV Amniocentesis and HIV positive women positive women

• Increased rate of vertical Increased rate of vertical transmissiontransmission

• Chemoprophylaxis previous to Chemoprophylaxis previous to amniocentesis appears to be amniocentesis appears to be beneficial in preventing vertical beneficial in preventing vertical transmissiontransmission

Multiple GestationMultiple Gestation

• Three methods:Three methods:– Indigo carmine injection to the first sacIndigo carmine injection to the first sac– A single needle puncture sampling A single needle puncture sampling

technique technique (Jeanty 1990)(Jeanty 1990)

– Simultaneous visualization of two Simultaneous visualization of two needles on each side of the separating needles on each side of the separating membrane membrane (Bahado-Singh 1992)(Bahado-Singh 1992)

– Abortion risk – probably higherAbortion risk – probably higher– Detailed description of fetus Detailed description of fetus

position and placental location position and placental location


Percutaneous umbilical blood Percutaneous umbilical blood sampling (CORDOCENTESIS)sampling (CORDOCENTESIS)


Percutaneous umbilical blood Percutaneous umbilical blood sampling (CORDOCENTESIS)sampling (CORDOCENTESIS)

CORDOCENTESISCORDOCENTESISInvolves the insertion of Involves the insertion of the needle directly into the needle directly into fetal umbilical vessel fetal umbilical vessel under ultrasound under ultrasound guidance and the guidance and the removing 1-4 ml of bloodremoving 1-4 ml of blood

CORDOCENTESISCORDOCENTESIS

Indications for useIndications for use• Prenatal diagnosis of inherited blood Prenatal diagnosis of inherited blood

disordersdisorders• Karyotyping of malformed fetusesKaryotyping of malformed fetuses• Detection of fetal infectionDetection of fetal infection• Determination of the acid-base status of Determination of the acid-base status of

fetuses with IUGRfetuses with IUGR• Assessment and treatment of Assessment and treatment of

isoimmunization and trombocytopenia in the isoimmunization and trombocytopenia in the fetusfetus

CORDOCENTESIS. CORDOCENTESIS. ComplicationsComplications

• Blood leaking from puncture siteBlood leaking from puncture site• Cord lacerationCord laceration• ThromboembolismThromboembolism• Preterm labourPreterm labour• Premature rupture of membranesPremature rupture of membranes• InfectionsInfections

BIOCHEMICAL BIOCHEMICAL ASSESSMENTASSESSMENT Chorionic villus sampling Chorionic villus sampling

BIOCHEMICAL BIOCHEMICAL ASSESSMENTASSESSMENT Chorionic villus sampling Chorionic villus sampling

Chorionic villus sampling Chorionic villus sampling (CVS)(CVS)

– Earlier diagnosis and rapid results Earlier diagnosis and rapid results – Performed between 10 and 12 weeks Performed between 10 and 12 weeks

of gestationof gestation– Removal of small tissue specimen Removal of small tissue specimen

from fetal portion of placentafrom fetal portion of placenta• Chorionic villi originate in zygote and Chorionic villi originate in zygote and

reflects genetic makeup of fetusreflects genetic makeup of fetus

Chorionic villus samplingChorionic villus sampling

• Was developed in the 80Was developed in the 80thth

• percutaneous transabdominalpercutaneous transabdominal• transvaginal transvaginal • transcervicaltranscervical

Chorionic villus sampling Chorionic villus sampling (CVS)(CVS)

• Complications:– vaginal spotting or bleeding immediately

afterward,– Miscarriage– Rupture of membranes, – chorioamnionitis.

• Because of the possibility of fetomaternal hemorrhage, women who are Rh negative should receive immune globulin (RhoGAM) to avoid isoimmunization.

Chemical Chemical determinationdetermination

Chemical Chemical determinationdetermination

SERUM MARKERSERUM MARKER

• Serum markerSerum marker– maternal maternal serum alphafetoprotein serum alphafetoprotein

MSMS--AFPAFP– maternal unconjugated maternal unconjugated estriolestriol– maternal serum beta-humanmaternal serum beta-human

chorionic gonadotropin (chorionic gonadotropin (hhCGCG))– OthersOthers

• • Pregnancy associated plasma Pregnancy associated plasma protein - A (protein - A (PAPP-APAPP-A))

• • Inhibin AInhibin A

SERUM MARKERSERUM MARKER

• Positive test indicates increased riskPositive test indicates increased risk• Negative test indicates no increased Negative test indicates no increased

risk but not mean normal fetusrisk but not mean normal fetus• Multiple fetuses cannot be assessedMultiple fetuses cannot be assessed

AFPAFP

• AFP is produced by the fetal liver, and increasing levels are detectable in the serum of pregnant women from 14 to 34 weeks.

• Approximately 80% to 85% of all open NTDs and open abdominal wall defects

• Screening is recommended for all pregnant women.

• If findings are abnormal, follow-up procedures include genetic counseling for families with a history of NTD, repeat AFP, ultrasound examination, and possibly amniocentesis.

Triple screeningTriple screening

(16-18 weeks)(16-18 weeks)• Maternal serum alpha-fetoprotein (MSMaternal serum alpha-fetoprotein (MS--

AFP)AFP)• Human chorionic gonadotropin (hCG)Human chorionic gonadotropin (hCG)• Unconjugated estriol (UE3)Unconjugated estriol (UE3)

Quadruple Screen Quadruple Screen ((15-22 weeks most accurate 16-18 weeks)15-22 weeks most accurate 16-18 weeks)

• AFP AFP • hCGhCG• UE3UE3• InhibinInhibin

Quadruple ScreenQuadruple Screen

hCGhCG EstradiEstradiolol

InhibinInhibin AFPAFP

Down Down SyndromeSyndrome

HighHigh LowLow HighHigh LowLow

Neural or Neural or abdominal abdominal

wall defectswall defects

NmlNml NmlNml NmlNml HighHigh

Trisomy 18Trisomy 18 LowLow LowLow LowLow LowLowDown SyndromeDown SyndromePAPP-A is lowPAPP-A is lowInhibin A is elevatedInhibin A is elevated

Electronic fetal Electronic fetal monitoringmonitoring

Electronic fetal Electronic fetal monitoringmonitoring

Indications for Electronic Fetal Monitoring Assessment Using NST

and CST• Maternal diabetes

mellitus • Chronic hypertension• Hypertensive

disorders in pregnancy

• IUGR• Sickle cell disease• Maternal cyanotic

heart disease• Postmaturity• History of previous

stillbirth

• Decreased fetal movement

• Isoimmunization• Meconium-stained

amniotic fluid at third-trimester amniocentesis

• Hyperthyroidism• Collagen disease• Older pregnant woman• Chronic renal disease

Contraindications for Electronic Fetal Monitoring Assessment

• NST– No – but results may not be conclusive if

• gestation is 26 weeks or less.• CST :

– rupture of membranes, – previous classic incision for cesarean birth, – preterm labor, – placenta previa,– placenta abruptio

– multifetal pregnancy, – previous preterm labor,– hydramnios, – more than 36 weeks of gestation, – incompetent cervix

Fetal Responses to Hypoxia or Asphyxia

• Hypoxia or asphyxia elicits a number of responses in the fetus. There is a redistribution of blood flow to certain vital organs. This series of responses (redistribution of blood flow favoring vital organs, decrease in total oxygen consumption, and switch to anaerobic glycolysis) is a temporary mechanism that enables the fetus to survive up to 30 minutes of limited oxygen supply without decompensation of vital organs.

• However, during more severe asphyxia or sustained hypoxemia, these compensatory responses are no longer maintained, and a decrease in the cardiac output, arterial blood pressure, and blood flow to the brain and heart occurs, with characteristic FHR patterns reflecting these changes.

Fetal heart rate Fetal heart rate terminologyterminology

• Baseline rateBaseline rate-110-160-110-160Bradycardia&TachicardiaBradycardia&Tachicardia• VariabilityVariability-Longterm & Short term-Longterm & Short term• AccelerationAcceleration• DecelerationDeceleration-Early-Early-Late-Late--VaribleVarible

NSTNST• is the most widely applied technique for antepartum

evaluation of the fetus.• Basis: the normal fetus will produce characteristic

heart rate patterns in response to fetal movement. • can be performed easily in an outpatient setting

because it is noninvasive. • relatively inexpensive and has no known

contraindications. • Disadvantages center around the high rate of false-

positive results for nonreactivity as a result of fetal sleep cycles, medications, and fetal immaturity.

• The test is also slightly less sensitive in detecting fetal compromise than are the CST and BPP.

NST InterpretationNST Interpretation• Two or more accelerations of 15 beats per minute

lasting for 15 seconds over a 20-minute period• Normal baseline rate• Long-term variability amplitude of 10 or more

beats per minute

• If the test does not meet the criteria after 40 minutes, it is considered nonreactive, in which case further assessments are needed with a CST or BPP.

• twice weekly (after 28 weeks of gestation) with patients who are diabetic or at risk for fetal death.

NSTNST• Reactive Reactive

– 2 or more accelerations of FHR of 15 beats/min lasting 2 or more accelerations of FHR of 15 beats/min lasting ≥15 sec, associated with each fetal movement in 20-min ≥15 sec, associated with each fetal movement in 20-min periodperiod

– Allow to continueAllow to continue

• NonreactiveNonreactive– Any tracing with either no FHR accelerations or Any tracing with either no FHR accelerations or

accelerations <15 beats/min or lasting <15 sec throught accelerations <15 beats/min or lasting <15 sec throught any fetal movement during testing periodany fetal movement during testing period

– CST, BBPCST, BBP

• Unsatisfectory quality of FHR recording not Unsatisfectory quality of FHR recording not adequate for interpretationadequate for interpretation– Repeated in 24 hours orRepeated in 24 hours or– CSTCST

CSTCST

• Uterine contractions decrease uterine blood flow and placental perfusion. If this decrease is sufficient to produce hypoxia in the fetus, a deceleration in FHR will result, beginning at the peak of the contraction and persisting after its conclusion (late deceleration).– Nipple-Stimulated

• 10 min massage • 2 min massage 5 min break

– Oxitocin-Stimulated• 10 U in 1000 ml fluid IV

CSTCST• NEGATIVE

– No late decelerations, with minimum of three uterine contractions lasting 40 to 60 sec within 10-min period

• Reassurance that the fetus is likely to survive labor should it occur within 1 wk; more frequent testing may be indicated by clinical situation

• POSITIVE– Persistent and consistent late decelerations occurring with more than

half of contractions• Management lies between use of other tools of fetal assessment such as BPP

and termination of pregnancy; a positive test result indicates that fetus is at increased risk for perinatal morbidity and mortality; physician may perform expeditious vaginal birth after successful induction or may proceed directly to cesarean birth; decision to intervene is determined by fetal monitoring and presence of FHR reactivity

• SUSPICIOUS– Late decelerations occurring in less than half of uterine contractions once

adequate contraction pattern established• NST and CST should be repeated within 24 hr; if interpretable data cannot be

achieved, other methods of fetal assessment must be used*• HYPERSTIMULATION

– Late decelerations occurring with excessive uterine activity (contractions more often than every 2 min or lasting longer than 90 sec) or persistent increase in uterine tone

• UNSATISFACTORY– Inadequate uterine contraction pattern or tracing too poor

CSTCST

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ASSESSMENT OF Fetal Well-being Lectures 3. Assessment of fetal well-being The major expected outcome...

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