Fetal assessmentFetal assessment

Dr. Khalid Khadawardi, MBBS. ARDMS. FRCSDr. Khalid Khadawardi, MBBS. ARDMS. FRCSMaternal-Fetal Medicine DivisionMaternal-Fetal Medicine DivisionOBS-GYN DepartmentOBS-GYN DepartmentUniversity of Umm-AlquraUniversity of Umm-Alqurakhadawardi@hotmail.comkhadawardi@hotmail.comkkhadawardi@imc.med.sakkhadawardi@imc.med.sa

ObjectivesObjectives

Indications Indications ModilityModilityTimingTimingManagmentManagment

INDICATIONSINDICATIONS

EVERY ONE

INDICATIONSINDICATIONS

Any patient at risk for developing decreased Any patient at risk for developing decreased utero-placental function, including:utero-placental function, including: Maternal DiseaseMaternal Disease

DiabetesDiabetes Chronic HypertensionChronic Hypertension Pregnancy-induced Hypertension, preeclampsiaPregnancy-induced Hypertension, preeclampsia Renal diseaseRenal disease Collagen dieasesCollagen dieases Cardiac diseaseCardiac disease Thyroid diseaseThyroid disease Significant hematologic disease (severe anemia, etc.)Significant hematologic disease (severe anemia, etc.) Thrid-trimester vaginal bleedingThrid-trimester vaginal bleeding

INDICATIONSINDICATIONS History of poor obstetric outcomeHistory of poor obstetric outcome Post-dates pregnancyPost-dates pregnancy Fetal indicationsFetal indications

Suspected intrauterine growth restriction (IUGR)Suspected intrauterine growth restriction (IUGR) Suspected decrease in fetal movementSuspected decrease in fetal movement Irregular or abnormal FHR by auscultationIrregular or abnormal FHR by auscultation Suspected Rh sensitizationSuspected Rh sensitization Multiple gestation with suspected IUGR or discordant Multiple gestation with suspected IUGR or discordant

growthgrowth Premature rupture of membranesPremature rupture of membranes Oligohydramnios/PolyhydramniosOligohydramnios/Polyhydramnios

ModilityModility

Maternal kick countsMaternal kick countsEFMEFMFetal blood samplingFetal blood samplingFetal Biophysical ProfileFetal Biophysical ProfileST-wave formsST-wave formsDoppler USDoppler US

MATERNAL KICK COUNTSMATERNAL KICK COUNTS

DescriptionDescriptionRecording the mother’s perception of fetal Recording the mother’s perception of fetal

activity. This is the oldest and most activity. This is the oldest and most inexpensive method of evaluating fetal well-inexpensive method of evaluating fetal well-being.being.

MATERNAL KICK COUNTSMATERNAL KICK COUNTS

InterpretationInterpretationDefinitions of decreased fetal movement Definitions of decreased fetal movement

include:include: >10 movements in 12 hours>10 movements in 12 hours 3 or fewer movements per hour3 or fewer movements per hour

ManagementManagement Normal kick count: repeat recordings dailyNormal kick count: repeat recordings daily Decreased or absent fetal movement: Decreased or absent fetal movement:

proceed with immediate evaluation and proceed with immediate evaluation and further testing (NST or BPP)further testing (NST or BPP)

FetoscopesFetoscopes

Determinants of FHRDeterminants of FHR

Intrinsic beating frequencyIntrinsic beating frequencyAction of nerves and hormones on the Action of nerves and hormones on the

heartheart

EFM: Problems and RealitiesEFM: Problems and Realities

Electronic Intra-partum FHR Monitoring is now Electronic Intra-partum FHR Monitoring is now considered mandatory for high-risk pregnanciesconsidered mandatory for high-risk pregnancies

Difficulties with interpretation include over confidence Difficulties with interpretation include over confidence and not-only difference in opinion between practitioners and not-only difference in opinion between practitioners but, also when the same practitioner examines the NST but, also when the same practitioner examines the NST twicetwice

Increases CS rates (RR 1.41)Increases CS rates (RR 1.41) Increases operative vaginal delivery (RR 1.20)Increases operative vaginal delivery (RR 1.20) No change in incidence of Cerebral PalsyNo change in incidence of Cerebral Palsy Reduction in Neonatal seizures rates (RR 0.51)Reduction in Neonatal seizures rates (RR 0.51) No difference in APGAR scoresNo difference in APGAR scores ?Efficacy?Efficacy

EFM- FactsEFM- Facts

Reliability of interpretation- 50-75% are Reliability of interpretation- 50-75% are false positivefalse positive

False positive Dx reduces to 10% with FBSFalse positive Dx reduces to 10% with FBS FBS 93% sensitivity, 6% false positiveFBS 93% sensitivity, 6% false positive

EFM- Basic FeaturesEFM- Basic Features

EFM- Basic FeaturesEFM- Basic Features

1.1. Baseline FHR – average FHR excluding accels and Baseline FHR – average FHR excluding accels and decels (110-160 bpm)decels (110-160 bpm)

TachycardiaTachycardia BradycardiaBradycardia

2.2. Baseline Variability - Baseline Variability - minor fluctuations of baseline FHR minor fluctuations of baseline FHR

at 3-5 cycles pmat 3-5 cycles pm between contractionsbetween contractions Absent (no amplitude range)Absent (no amplitude range) Minimal (Minimal (< < 5bpm) 5bpm) Moderate (6-25 bpm)Moderate (6-25 bpm) Marked (> 25 bpm)Marked (> 25 bpm)

Baseline variability CTGBaseline variability CTG

Minimal

Moderate

Marked

6

EFM - AccelerationsEFM - Accelerations

Transient increase in FHR of 15 bpm x Transient increase in FHR of 15 bpm x 15 sec15 sec

EFM - DecelerationsEFM - Decelerations

Transient slowing of FHR below the baseline Transient slowing of FHR below the baseline level of more than 15 bpm x level of more than 15 bpm x >> 15 sec 15 sec EarlyEarly VariableVariable LateLate ProlongedProlonged

Late DecelerationsLate Decelerations

Variable DecelerationsVariable Decelerations

Prolonged DecelerationProlonged Deceleration

Sinusoidal patternSinusoidal pattern

EFM-SummaryEFM-Summary

Normal Normal Non-reassuring vs reassuringNon-reassuring vs reassuring

“Holy milk bottle, I’ve been cloned”

Fetal Blood SamplingFetal Blood Sampling

CordocentesisCordocentesis

Fetal scalp pH.Fetal scalp pH.

Fetal Blood SamplingFetal Blood Sampling information on the acid base balanceinformation on the acid base balance Has 6%-20% false negative (i.e., normal)Has 6%-20% false negative (i.e., normal) 8-10% false positive (i.e., low values)8-10% false positive (i.e., low values) Why and when to do:Why and when to do:

Persistent Abnormal CTG after reversible factors have been Persistent Abnormal CTG after reversible factors have been correctedcorrected

Persistent late decels and 2 abnormal other features e.g Persistent late decels and 2 abnormal other features e.g baseline tachycardia or reduced B-B variability or just difficult to baseline tachycardia or reduced B-B variability or just difficult to interpret the CTGinterpret the CTG

ROM, accessible and well applied Cx (ROM, accessible and well applied Cx (>> 3 cm) 3 cm) Sterile environment, good light and equipmentSterile environment, good light and equipment Good analgesiaGood analgesia

FBS - Cord pHFBS - Cord pH

FBS-ArterialFBS-ArterialNormal-7.25-7.35Normal-7.25-7.35Less than 7.20-significant asphyxiaLess than 7.20-significant asphyxia

Imminent deliveryImminent deliveryValues between 7.2 and 7.24 need further Values between 7.2 and 7.24 need further

evaluationevaluationshould be repeated in 30 mimshould be repeated in 30 mim

FBS ContraindicationsFBS Contraindications

FetalFetalPremature – Premature – << 34 wks 34 wksActive HerpesActive HerpesKnown HIV,Hep B/C positive statusKnown HIV,Hep B/C positive statusThrombocytopeniaThrombocytopeniaMaternalMaternalUnfavourable CxUnfavourable CxMobile PPMobile PPMalpresentation(face etc) uncertain??Malpresentation(face etc) uncertain??Placenta Praevia or APHPlacenta Praevia or APHSepsis Sepsis

FBS-Sampling errorsFBS-Sampling errors

Between decelerations if possibleBetween decelerations if possibleAvoid Excess pressure on head: reduces Avoid Excess pressure on head: reduces

perfusionperfusionDo not sample on the caputDo not sample on the caputFailure of scalp to bleed – due to Failure of scalp to bleed – due to

peripheral shut downperipheral shut down

Fetal US scanFetal US scan

Structural scanStructural scanGrowth assessmentGrowth assessmentPlacenta locationPlacenta locationMorphologyMorphology

Functional scanFunctional scanBPPBPPDopplerDoppler

BIOPHYSICAL PROFILEBIOPHYSICAL PROFILE

BPP is a physical examination of the fetus utilizing real-BPP is a physical examination of the fetus utilizing real-time ultrasound in combination with the NSTtime ultrasound in combination with the NST

BPP is based on assessment of five biophysical BPP is based on assessment of five biophysical

variables which include: variables which include: 1. Fetal breathing movements (FBM) 1. Fetal breathing movements (FBM)

2. Gross body fetal movement (FM) 2. Gross body fetal movement (FM) 3. Fetal tone (FT) 3. Fetal tone (FT) 4. Amniotic fluid volume (AFV) 4. Amniotic fluid volume (AFV) 5. Nonstress test (NST) 5. Nonstress test (NST)

BIOPHYSICAL PROFILEBIOPHYSICAL PROFILE

The variables are scored according to the fixed The variables are scored according to the fixed criteria and assigned a score of 2 if normal and 0 criteria and assigned a score of 2 if normal and 0 if abnormal. if abnormal.

The NST portion of the BPP may be excluded. The NST portion of the BPP may be excluded. Its absence does not alter test accuracy but Its absence does not alter test accuracy but does improve its efficiency. does improve its efficiency.

The duration of real-time observation is The duration of real-time observation is extended until normal criteria have been met for extended until normal criteria have been met for each biophysical variable or a maximum period each biophysical variable or a maximum period of 30 minutes has elapsed. of 30 minutes has elapsed.

BIOPHYSICAL BIOPHYSICAL VARIABLE VARIABLE NORMAL (SCORE =2) NORMAL (SCORE =2) ABNORMAL (SCORE =0) ABNORMAL (SCORE =0)

FETAL FETAL BREATHING BREATHING MOVEMENTS MOVEMENTS (FBM) (FBM)

At least 1 episode of at least At least 1 episode of at least 30 seconds in duration in 30 30 seconds in duration in 30 minute observation minute observation

Absent FBM or episode of <30 Absent FBM or episode of <30 seconds in 30 mintues seconds in 30 mintues

GROSS BODY GROSS BODY MOVEMENTS (FM) MOVEMENTS (FM)

At least 3 discrete body/limb At least 3 discrete body/limb movements in 30 mm movements in 30 mm (episodes of continuous (episodes of continuous movement considered as movement considered as single movement) single movement)

2 or fewer episodes of 2 or fewer episodes of body/limb movements in body/limb movements in 30 mm 30 mm

FETAL TONE FETAL TONE

At leat 1 episode of active At leat 1 episode of active extension with return to extension with return to flexion of fetal limb(s) or flexion of fetal limb(s) or trunk. Opening and closing of trunk. Opening and closing of hand considered normal tone hand considered normal tone

Either slow extension with Either slow extension with return to partial flexion or return to partial flexion or movement of limb in full movement of limb in full extension or absent fetal extension or absent fetal movement movement

AMNIOTIC FLUID AMNIOTIC FLUID VOLUME (AFV) VOLUME (AFV)

At least 1 pocket of AF that At least 1 pocket of AF that measures at least 2 cm in 2 measures at least 2 cm in 2 perpendicular planes (or AFI perpendicular planes (or AFI >5cm) >5cm)

Either no AF pockets or a Either no AF pockets or a pocket < 2 cm in two pocket < 2 cm in two perpendicular planes (or AFI, perpendicular planes (or AFI, <5cm) <5cm)

NONSTRESS TEST NONSTRESS TEST (NSI) (NSI)

At least 2 episodes of FHR At least 2 episodes of FHR acceleration of> 15 beats/mm acceleration of> 15 beats/mm and of at least 15 sec duration and of at least 15 sec duration associated with fetal associated with fetal movement in 10 mm movement in 10 mm

Less than 2 episodes of Less than 2 episodes of acceleration of FHR or acceleration of FHR or acceleration of< 15 beats/mm acceleration of< 15 beats/mm in 10 mm in 10 mm

Perinatal Mortality and the Biophysical Profile Perinatal Mortality and the Biophysical Profile ScoreScore

ScoreScore Perinatal Mortality/1000Perinatal Mortality/1000

8-108-10 1.861.86

66 9.769.76

44 26.326.3

22 94.094.0

00 285.7285.7

Amniotic fluid volume- oligo is frequently associated Amniotic fluid volume- oligo is frequently associated with IUGR (↓ blood volume ,↓ renal blood flow, ↓ urine with IUGR (↓ blood volume ,↓ renal blood flow, ↓ urine output)output)Perinatal morbidity ↑ 10 times if oligo present.Perinatal morbidity ↑ 10 times if oligo present.IUFD in 5 – 10 % if oligo present.IUFD in 5 – 10 % if oligo present.IUFD with Bpp 8/8 is 0.7 in 1000 birth. Vs 40% if score IUFD with Bpp 8/8 is 0.7 in 1000 birth. Vs 40% if score is 0/8..is 0/8..False –ve is < than 1 / 1000.False –ve is < than 1 / 1000.

Biophysical profile Biophysical profile

ST-wave formsST-wave forms

Doppler UltrasoundDoppler Ultrasound

• Arterier systemArterier system::

• Middle cerebral arteryMiddle cerebral artery

• Aorta Aorta

• Umbilical arteryUmbilical artery

• Uterine arteryUterine artery

• Venus systemVenus system::

• IVCIVC

• Ductus venosusDuctus venosus

• Umbilical venUmbilical ven

• Tricasped valveTricasped valve

MCAMCA

Fetal AortaFetal Aorta

Umbilical arteryUmbilical artery

Uterine arteryUterine artery

DUCTUS VENOSUMDUCTUS VENOSUM

Umblical VeinUmblical Vein

FGRFGR

Abnormal arterialAbnormal arterial DopplerDoppler

Abnormal venousAbnormal venousDopplerDoppler

Low BPPLow BPPScoreScore

Non reasuringNon reasuringNSTNST

2-8W2-8W

1-4W1-4W

1-2D1-2D

12-24H12-24H

Timeline for Fetal distresTimeline for Fetal distres

Take-home pointsTake-home points

Fetal health surveillance aims at Fetal health surveillance aims at improving fetal outcomes by improving fetal outcomes by identifying those with hypoxic identifying those with hypoxic acidemia & intervening while it is still acidemia & intervening while it is still reversiblereversible

Take-home pointsTake-home points

The reliability, validity, & efficacy of EFM The reliability, validity, & efficacy of EFM remain contentiousremain contentious

Fetal biometry and arterial Doppler the Fetal biometry and arterial Doppler the early signearly sign

Venous Doppler, FHR analysis, and the Venous Doppler, FHR analysis, and the biophysical profile represent the later biophysical profile represent the later stages(commonly associated with fetal stages(commonly associated with fetal acidosis)acidosis)