Fetal growth and well-being

DATING SCAN

SAC FROM 5WKS

FETAL POLE 6WKS

FETAL HEART 7 WKS

LIMB BUDS 8 WKS

HEAD 12WKS

NT 11 TO 14 WKS

FULL ANOMALY 18-20 WKS

BPDHCFACFEMUR LENGTH

CROWN RUMPLENGTH

ANOMALIES – ULTRASOUND 18 TO 20 WEEKS

Spina BifidaAnencephalyCardiacRenalDiaphragmatic hernialimbs FacialChromosomal

Late > 20/40

RenalMicrocephalyHydrocephalusUreteral valves

aFP

ULTRASOUND GUIDANCE

AMNIOCENTESIS, L/S RATIO

CVS

CORDOCENTESIS, TRANSFUSION

PARACENTESIS

SHUNTS bladder, asciteskidney, head

LIVER BIOPSY, SKIN

FETAL REDUCTION

OTHER OBSTET

Estimated fetal weight

Twins discordance

Behavioural states ( B.P.S. )

Presentation

Placenta ( previa, RPC’S)

DEFINITION OF I.U.G.R

Less than 2500 grams

SGA vs AGA

Less than 5 centile for GA

Approx. 4 - 7 % of all infants are IUGR

Appropriate screening tests in an early,

uncomplicated pregnancy include all of

the following except:

a) repeat human chorionic gonadotropin

b) hemoglobin

c) syphillis serology

d) cervical cytology

e) blood type and Rh factor

CAUSES OF I.U.G.R

MATERNAL FACTORS

• Malnutrition• Drugs• Substance Abuse• Diseases• Infections

CAUSES OF I.U.G.R

FETAL CAUSES

- Chromosomal Abnor mality

- Congenital Abnor mality

- Multiple Gestation

- Congenital Infection

CAUSES OF I.U.G.R

PLACENTAL FACTORS

Placental Perfusion

Placental Abnormalities

- Abnormal Cord Insertion- Abruption- Circumvallate placentation- Placental Memangioma- Placental Infection- Twin to Twin Transfusion

CAUSES OF FETAL OVERGROWTH

Maternal Diabetes

Maternal Obesity

Excessive Maternal Weight Gain

IMMEDIATE NEONATAL MORBIDITY IN IUGR

Birth asphyxiaMeconium aspirationHypoglycemiaHypocalcemiaHypothermiaPolycythemia, hyperviscosityThrombocytopeniaPulmonary hemorrhageMalformationsSepsis

CLINICAL TESTSFundal heightMaternal weightFetal Kicks

BIOCHEMICAL TESTSaFPHPLoestriolcrf

CARDIOTOCOGRAPHYStress testsNon stress tests

ULTRASOUNDGrowth parametersFetal weightAmniotic fluid volumeBiophysical profile score

DOPPLER

FUNDAL HEIGHTS - F HEIGHT IN cms + 2 = no of weeks

Sensitivity 60 %

Use of S - F charts

MATERNAL WEIGHTwks gain

0 - 20 4 kg21 - 28 4 kg29 - 40 4 kg Average 12 kg

Not very reliable guideBig mother

BIOPHYSICAL PROFILECTG 0 - 2MOVEMENTTONELIQUOR VOLUMEBREATHING

MAX. 10

DOPPLERWhat is it?Uteroplacental waveformsUmbilical arteryCarotid arteryDescending aorta

FETAL ACTIVITY

Cardiff “count to ten “ chart

towards term

10 movements in 12 hours

Randomized study

CARDIOTOCOGRAPHYMaybe as good as BPP

Non - stress movement

uterine activity

Stress testsSyntocinon infusion

nipple stimulation

Features of the normal CTG

rate 120 - 160BTB variation 5 - 15Accelerations presentNo decelerations

The perinatal mortality rate is defined as :

a) the number of neonatal deaths that occurper 1000 live births

b) the number of still births that occur per1000 births

c) the number of fetal deaths within the firstweek after birth

d) the number of still births and neonataldeaths per 1000 live births

WHY FETAL ASSESSMENT ?1. To prevent damage (asphyxia)

2. To deter unnecessary intervention ( prematurityoperative deliveries )

WHICH FETUSES SHOULD BE ASSESSEDALL FETUSES ?

small for gestational : age v postdates

maternal hypertension, Diabetes

antepartum hemorrhage

FM’ s etc.....

The “high risk” pregnancy

WHAT IS TEST LOOKING FOR ?

FETAL HYPOXIA BEFORE ASPHYXIA

PLACENTAL FAILURE

Poor growth

movmt, liquor

Poor CTG

The essential characteristics of asphyxia (hypoxic acidemia) are:

• umbilical cord arterial pH < 7.0

• base deficit > 16

• Apgar score 0 – 3 for > 5 minutes

• neonatal neurologic sequelae (e.g.,seizures, hypotnia, coma)

• evidence of multiorgan system dysfunction in the immediate

neonatal period.

FETAL HEART RATE IN LABOUR

Baseline 120 - 160 b.p.m

Variability > 5 b.p.m

Accelerations present

DECELERATIONS EARLYVARIABLELATE

pH sampling normal > 7.25borderline 7.25 - 7.2deliver < 7.2

NORMAL TRACE

Early decels

Early decelerations

Late decelerations

Variable decals

Reduced variability

Tachycardia

Percentage distribution of acidity states in different groups of cardio-tocographical findings according to the HAMMACHER score.

Effect on: Odds Ratio (95% CI)Treatment: Control

All caesarean sectionsCaesareans for fetal distressCaesareans for failure to progressOperative vaginal deliveriesApgar score <7 at one minuteApgar score <4 at one minuteAdmission to special care nurseryNeonatal seizuresAll perinatal deathsIntrapartum deathsAll operative deliveriesGeneral anaesthesiaCerebral palsyCerebral palsy after neonatal seizureLow Bayley mental development indexLow Bayley psychomotor index

1 2 4 100.1 0.3 0.5

EFM + scalp sampling vs intermittent auscultation in labour (6 trials reviewed)

Treatment better Treatment worse

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AN IDEAL TEST ?

1. A simple screening test performed in early pregnancy to see whether or not a risk exists.

2. Low rate of false positives and false negatives

3. Cheap

4. Safe

5. Painless

6. Not anxiety inducing for mom

7. Fully assessed

OTHER TESTS

CORDOCENTESIS

FETAL ECG

INFRA RED

CONTINUOUS pH

ARE TESTS ANY USE ?

Need randomized trials but poor oucomes are infrequent

Usually a normal test will result in a favourable outcome

Characteristics or associated findings with latedecelerations include all of the following except:

a) they may be seen in patients with pre-eclampsia

b) they may be associated with respiratory alkalosis

c) they are associated with a decreased uteroplacental blood flow

d) they often are accompanied by decreased PO2

e) they usually are accompanied by an increased PCO2