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ANTEPARTUM FETAL MONITORING & CARDICTOGRAPHY

• Antepartum Foetal monitoring: Following tests can be done:

• DFMC:
▪ Daily foetal movement count
▪ Mother is asked to keep the check on the daily movements of foetus
▪ If mother is able to count 10 movements within 2 hours, then it is normal
▪ CARDIFF COUNT TO 10 →>= 10 movements in 2 hours, then it is okay
• NST:
▪ Non-stress test
▪ Based on the fact that with foetal movements the foetal heart rate
accelerates

• A toco probe is placed over fundus for uterine contractions

• Cardio probe is placed over where foetal heart is heard
• Mother has a button in her hand which she presses when she perceives movement

▪ Graph:

• Paper speed @ 3cm/min

• Take a 2-minute segment & draw line
between highest & lowest points;
this line is baseline foetal heart rate
• The FHR baseline is not a straight line but varying from beat to beat.Beat to beat
variability
• Rise in foetal heart rate above baseline is Acceleration

Note: Reactive NST:

▪ +nce of at least 2 accelerations in 20 minutes’ period

▪ Each acceleration should be at least 15 beats per minute [bpm] at least lasting
for 15 seconds
▪ If NST is reactive then it is a good sign as risk of foetus dying in next 7 days is
only 1%

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▪ If NST is reactive then repeat it weekly or biweekly depending on r isk level of
pregnancy
▪ Cause of foetus dying with a reactive NST:
• Acute accidental event like
• Meconium Aspiration
• Placental Abruption
• Intrauterine infection
• Biophysical Profile/ Manning’s Score”
▪ Done for 30 minutes
▪ 5 components of Biophysical profile ”
• NST
• Foetal breathing → at least 1 episode be +nt for >= 30secon ds
• Gross body movement → atleast 3
• Foetal tone → atleast 1 episode of flexion & extension
• Amniotic fluid [AF] volume →at least 1 pocket of 2x2 cm should be +nt
▪ If a feature is +nt → 2 score, -nt → 0 Score
▪ Thus, total score → 10
▪ Except NST, all other 4 features are observed by USG which is conducted for
full 30 minutes
▪ AF volume tells about chronic condition Example: Chronic Uteroplacental
insufficiency. Rest all features tell about current status of baby
▪ If score is
• 8/10 or 10/10 → Normal
• AfraTafreeh.com
<=4/10 → Abnormal; baby needs to be delivered
• 6/10 → Borderline; repeat the test same day
▪ With fetal compromise, the first feature to be abnormal is NST & last feature to
go is Foetal tone.

Modified Biophysical Profile:

▪ Consumes less time

▪ Includes NST + AF index

VAST:

▪ Vibro Acoustic Stimulation test

▪ Sometimes NST is non-reactive because the baby is sleeping; in that case we
wake the baby up by VAST and re-do the NST
▪ Give 3 stimulations for up to 3 seconds , using an artificial larynx

Contraction stress test:

▪ Not commonly used

▪ Done to see if the foetus would tolerate contractions
▪ Oxytocin is given by i.v. infusion to setup the contractions, then foetal HR is
monitored in a similar way as done in NST
▪ Do not do this test when vaginal delivery is contraindicated or when the foetus is
extremely compromised already
▪ Contraindications:
• Placental Previa
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• IUGR with Doppler Changes

• Previous C-section
• Any C/I for vaginal delivery

INTERAPARTUM FOETAL MONITOR ING; CARDIOTOCOGRAPHY:

Normal trace:

▪ Baseline 110-160/min
▪ Beat to beat variability 5-25 bpm [if
normal it indicates that ANS of foetal is
functional and intact]
▪ Accelerations can be +nt or -nt
▪ Decelerations absent

Types of Decelerations:

Type 1:

• Early Deceleration
• Foetal HR starts decreasing with the start of contractions
• Lowest point of foetal HR is seen at the peek of contraction [mirror image]
• By the end of contraction, the foetal HR becomes normal

Early deceleration occurs d ue to head compression during the contraction

• Type 2:
• Late decelerations
• There is delay in fetal heart rate

deceleration when we compare it with

the contractions

• Foetal HR Deceleration that persists

even after contraction is over is late
deceleration
• It signifies:
▪ Foetal Hypoxia
▪ Uteroplacental Insufficiency
▪ Foetal Asphyxia
• Other causes of late deceleration – excessive uterine contractions that is
Tachysystole [> 5 contractions /10 min]
• Maternal Hypotension can lead to uteroplacental insufficiency & th us, late
deceleration
• Epidural Analgesia
• Dehydration
• Prolonged Supine Position

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Type 3:

• Variable deceleration
• Foetal HR deceleration is very sharp ,time taken
from its start to the lowest point of
deceleration is <30 sec
• It is not related to the contractions

A/W cord compression during labour

• Sinusoidal Pattern of Baseline:

• Sine Wave pattern of foetal HR is seen
• Beat to beat variability is lost
• Seen in:
▪ Extreme foetal asphyxia [severe]
▪ Sudden Foetal Anemia:
• Rh isoimmunised pregnancy
• Sudden intracranial bleeding
during labour
• Bleeding from vasa previa
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• Twin to twin transfusion syndrome

• Clinical Management of CTG:

• Routine use of CTG has not prevented perinatal morbidity or mortality
• CTG use has increased the incidence of C -section
• Category I CTG →
▪ Normal CTG
▪ Continue monitoring
• Category III CTG →
▪ Abnormal CTG
▪ Expedite delivery
• Category III CTG means there is:
▪ Absent variability + any of the three:
• Persistent late decelerations [when decelerations are seen in at
least 50% contractions in 20 -minute period]
• Persistent variable deceleration
• Persistent bradycardia
▪ Sinusoidal pattern

o With category 2 trace – i.e. neither Cat 1 nor Cat 2 (suspicious). We try corrective
measures first like -
• Stop oxytocin + Give i.v fluids
• Shift woman to the lt. lateral position that improves placental oxygenation

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• Start O2 by mask
• DO P/V examination
• Continue CTG;
• if after these steps foetal HR becomes normal then good otherwise go for
C-Section
•
• Other methods of intrapartum foetal monitoring:
• Foetal Scalp blood sampling: We check for pH of foetal blood.
▪ If pH >7.25 → Normal
▪ pH < 7.20 → Foetus is acidotic; should be delivered
▪ pH 7.20 -7.25 → Repeat after 30 minutes
• Scalp stimulation Test
• Pulse Oximetry – If O2 saturation < 30 % for 2 minutes then it is abnormal

ANEUPLOIDY SCREENING PRENATAL DIAGNOSIS

• Aneuploidy:
• Monosomy X→ 98% cases abort in 1st trimester
• Trisomy 18→ 85% cases about between 10 -40th week
• Trisomy 21→
• Only 30% abort between 10th-40th week
• Down’s Syndrome
• Whom to offer screening?
• Increasing Maternal age increases the risk of carrying a down’s syndrome
foetus
Age Risk
30 years 1 in 1000
35 years 1 in 385
40 years 1 in 100
45 years 1 in 30
o But Screening should be offered to all women irrespective of their age
• If there is history of previous affected child?
• High risk of recurrence
• In such cases we do not conduct screening test instead we go for Direct
Invasive Testing
• How to calculate Risk of Recurrence?
▪ It depends on the type of Down’s Syndrome the affected child has:
• 95% [Most common down’s syndrome] →Non-Disjunction Type
• 4% → Translocation type
• Rare → Mosaic Type
▪ Check the karyotype of the Affected Child’s:
▪ If Non-Disjunction Type→ Risk of recurrence is 1%
▪ If Translocation type → Go for parental karyotype:
• If Translocation is inherited from either of parents, parental karyotype
will also show the translocation:
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 o If translocation is t[13,14,15] with t[21] → Risk of recurrence is 2-15%
o t[21,21] in either parent → 100% Recurrence
• If Parents are normal, that means the fetal translocation happened is
de novo → Risk of Recurrence is 1%
• Screening Tests:
• 1st trimester combined screening test:
▪ Done between 11 to 13 + 6 weeks
▪ Components:
• On ultrasound we see NT that is Nuchal translucency
• Serum PAPP-A
• Serum βHCG
• Detection rate [DR] – 85%
• Triple Test
▪ Biochemical test
▪ Done between 15-20 weeks
▪ Best between 16-18 weeks
▪ Components:
• βHCG
• MS-AFP
• Unconjugated Estriol
▪ DR → 60-70%

• Quadruple Test [Quad test]

▪ Biochemical testAfraTafreeh.com
▪ Done between 15-20 weeks
• Components:
• βHCG
• MS-AFP [Maternal Serum α-Fetoprotein Estriol]
• Unconjugated Estriol
• Inhibin A
• DR → 80%
• Integrated Screening:
▪ Combination of 1st trimester combined screening test & quad test
▪ DR → 94-96%
• Note:
▪ In Down’s Syndrome out of all Markers:
• HCG & Inhibin A → Increases
• Unconjugated Estriol, MS-AFP, PAPP-A → decreases
▪ In down syndrome in 1st trimester βHCG increases, PAPP-A decreases
but in trisomy 18 both HCG & PAPP-A decreases

▪ Problems with Screening →

• Even if screening tests are positive, the positive predictive
value [PPV] is only 3-5%
• There is a false positive rate of 5% with the screening tests
• Therefore, Invasive testing is always r equired to confirm the
diagnosis
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•
• Clinical Scenarios to diagnose Down’s Syndrome:
• Screening tests positive → Invasive Testing done
• A woman can come with USG markers suggestive of aneuploidy
These marks can be +nt in:
▪ 1st Trimester
▪ 2nd Trimester
• 1st trimester markers:
• Nuchal Translucency [NT] = fluid
collection under the nape of the neck
• We can measure NT between 11-14
weeks. When the CRL of embryo
is 45-84 mm]
• It should be measured in sagittal
plane of foetus
• Raised NT:
▪ NT >= 3mm is Abnormal
• Raised NT indicates risk of
down’s syndrome > Turner’s
syndrome > Cardiac anomalies
• In twins - NT is most important
markers for screening aneuploidy
• Absent Nasal Bone = is another
ultrasound marker for aneuploidy
• Cystic Hygroma =
▪ Results from lymphatic swelling in the region of neck
▪ If cystic hygroma is seen in 1st trimester

there is risk of Down’s Syndrome > Turner’s Syndrome > Trisomy 18 > Cardiac Anomaly

• Whenever cystic hygroma is diagnosed in 2 nd trimester

• the most common anomaly associated
isTurner’s Syndrome [75% cases]
• Absent ‘a’ wave in Ductus Venosus
• Tricuspid Regurgitation

• 2nd trimester markers:

• Aka soft markers because when they
are +nt individually they confer slight
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 risk but when a number of markers are +nt together they increase the risk
substantially

• 2nd trimester Sonographic

markers a/w Foetal trisomy 21
are:
▪ Clinodactyly [Hypoplasia of 5 th
digit middle phalanx]
▪ Echogenic bowel
▪ Flat facies
▪ Echogenic Intracardiac Focus
▪ Nasal bone absence or
Hypoplasia
▪ Nuchal Skin fold thickening [not Nuchal transluce ncy]
▪ Renal Pelvis dilation
▪ Sandal gap between 1st and 2nd toes
▪ Single transverse palmar crease
▪ Single Umbilical artery
▪ Short femur, short humerus
▪ Widened iliac angle
• Nuchal Fold thickness [NFT]:
▪ Abnormal when >= 6mm
▪ AfraTafreeh.com
As an isolated marker maximum
risk is seen in raised NFT
• Note: As an isolated marker choroid plexus Cyst has no risk
• If isolated soft marker is found on USG, we can go for:
▪ Screening Test [if not done already]
▪ Cell free foetal DNA testing [Cf Foetal DNA testing]:
• Expensive screening test
• Aka non invasive prenatal test [NIPT]
• Sample is taken from maternal blood
• In maternal blood, the tissue which needs to be isolated is cell free foetal
DNA
• This DNA comes from apoptotic placental trophoblast s which are in contact
with maternal blood
• This Cf Foetal DNA can be detected in maternal blood from 10 weeks
onwards to term
• Atleast 4% CF DNA should be +nt in circulation to become detectable
• Very expensive screening test which needs to be confirmed
• Advantage:
o High DR of 99% in high risk women like Age > 35
o False positive rate is less 0.5%
• If CF Foetal DNA positive → invasive testing is still required to confirm
the diagnosis
• If CF Foetal DNA negative, → We can avoid invasive testing
• Currently this test is available for trisomy 21, 18, 13, Monosomy X
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• Invasive Test:
• Chorionic villus Sampling [CVS]
• Amniocentesis
• Cordocentesis /PUBS; Percutaneous Umbilical blood sampling
CVS Amniocentesis
Sample is taken from Sample is amniotic fluid
Chorionic villi containing foetal cells,
Fetal dermal fibroblasts and
amniocytes
Catheter is introduced Needle is introduced into
trans cervically or per amniotic cavity
abdominally
Timing: Timing:
• Done between 10-13 • Done between 15-20
weeks weeks
• If done at < 9-weeks • Best at 16-18 weeks
it can lead to limb
reduction defects
Sample: Sample:
• Chorionic villi so • Amniocytes & foetal
trophoblasts are dermal fibroblasts
taken
Result: Results:
• As trophoblasts are • As amniocytes &
dividing cells earlier foetal dermal
result available fibroblasts are non-
between 24-48 hours dividing cells they
need to be cultured
1st,Thus results are
available in 7-10 days
Foetal Loss Rate: Foetal Loss Rate:
• 1% [Overall risk in • 0.5% [Procedure
CVS is more than related is same in CVS
Amniocentesis &Amnio]
What defects are tested?
A] DNA Anomalies Same
B] Chromosomal Same
Abnormalities
C] Karyotype Abnormalities Same
D] Single gene disorders Same
E] foetal Infections Same
F] Foetal Anaemia [in case of
Rh Iso immunisation]
G] Tests for Neural Tube
disorders [NTD] by checking
Amniotic Fluid Ach Esterase]
Important Topics
PUBS
umbilical vein is sampled
[If accidental umbilical artery
is pricked it will cause: Spasm
of UA and risk of Foetal
mortality]
Needle is inserted close to
placental insertion where
umbilical cord is steady & fixed
Timing:
• Can be done anytime
beyond > 18-20 weeks
Sample:
• Foetal Blood cells
Results:
• As foetal blood cells are
dividing cells earlier
result is possible
between 24-48 hours
Foetal Loss Rate:
• Overall risk is maximum
in cordocentesis
Same
Same
Same
Same
Same
F] Foetal Anaemia
G] Use it for intrauterine
transfusion
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• Neural Tube Disorders [NTDs]
• Congenital malformation which results due to failure of closure of neural
tube
• Example:
▪ Anencephaly
▪ Spina Bifida
▪ Meningocele
▪ Meningomyelocele
• Neural tube disorders are 2 nd most common gross Congenital anomalies [most
common is CVS anomalies]
• Multifactorial Disorders:
▪ Environmental
▪ Genetic
▪ Maternal Diabetes
▪ Drugs [Antifolates, Antiepileptics]
• Periconceptional Folic acid administration that is atleast 1 month prior to
conception is advised for all the women who try to conceive & it should be
continued for 3 months after conception, Dose - 400μg /day of Folic acid
• If there is history of prior affected child with neural tube defect, then
risk of recurrence increases as:
▪ 1 prior child → Risk of recurrence is 5%
▪ 2 prior child → Risk of recurrence is 10%
▪ In such cases the Dose is 4mg/Day which decreases the risk of
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recurrence by 70-80%
• Women with diabetes or on antiepileptic drugs →
▪ Dose of FA = 4mg/day
▪ Note that correction of diabetes will mainly decrease risk
• Thus, Folic acid intake does not prevent neural tube defect completely
• Anencephaly:
• Earliest anomaly that can be diagnosed on USG; as early as 10 weeks &
definitely by 14 weeks
• Can be diagnosed in 1st trimester
• Associated Signs:
• Frog eye sign Mickey mouse head

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• Associated with:
▪ Polyhydramnios Because pituitary gland is -nt so swallowing reflex is -
nt
▪ A/w both post term > preterm
▪ a/w face presentations in labour
▪ a/w pseudo shoulder dystocia [shoulder stuck behind incompletely
dilated cervix]
• Spina Bifida:
• 2 USG markers a/wspina bifida are:
• Lemon Sign:
• Due to frontal bone scalloping
• Banana Sign:

▪ Curved Cerebellum like a banana]

• Note: Neural Tube defects can be diagnosed by:
▪ USG
▪ Estimating amniotic fluid Ach-Esterase which rises in open NTDs [best
diagnosis method for NTDs, but invasive procedure so not used
routinely]
▪ NTDs are a/w increased maternal serum AFP levels.
▪ When maternal serum AFP are raised, the next step is targeted
sonography to look for NTDs(do not directly go for invasive technique)

PUERPERIUM “NORMAL & ABNORMAL”

• Puerperium:is the period when after pregnancy the uterus & the reproductive
tract & all the pregnancy related changes & maternal adaptive changes that have
happened during pregnancy come back to the non -pregnant state
• Changes in Genital Tract:
▪ Hymen:
▪ In child → very thin hymen
▪ In adult → Vascular, thicker hymen
▪ After childbirth → only membranous tags of hymen at varying
locations all around the vaginal introitus, these are called Carunculae
Myriteformes

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 ▪ Uterus:
▪ Immediately after delivery the uterine fundus lie just below umbilicus
that is approx. 13.5 cm above the symphysis pubic
▪ It decreases in size due to uterine contractions
▪ Becomes 100gm at 4 weeks
▪ Becomes pelvic organ in about 2 weeks
▪ Complete involution of uterus takes 6 weeks
▪ Placental site involution takes 6 weeks
▪ Lochia:
▪ Per vaginal discharge of superficial layer of Decidua Basalis along with
necrotic tissue, blood cells, WBCs
▪ Lochia is Rubra [Red in colour] till Day 4
Serosa till Day 10
Alba [white in colour] after Day 10
▪ As the superficial layer of decidua basalia is shed off as lochia, i t is
the Basal layer of Decidua Basalis which is going to cause new
endometrial regeneration.
▪ Histology → Regenerative endometritis
▪ After pains:
▪ Are because of uterine contractions that oocur in the puerperium
period
▪ Reported more in multi-gravida
▪ Worsen on suckling by infant because of release of oxytocin which
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causes milk ejection as well as uterine contractions
▪ Mild by Day 3
• Causes of Subinvolution of uterus:
▪ Any genital infection; mainly endometritis
▪ Any retained tissue that gets infected or interfere with uterine
contractions
▪ Anaemia [healing is better when blood supply is good]
• Physiological changes in Puerperal Period:
▪ GFR come back to normal by 2 weeks
▪ Initially, there is postpartum diuresis (water retained during pregnancy is
lost by diuresis)
▪ Blood volume becomes normal by 1 week
▪ Cardiac output remains high during immediate postpartum period that is 24 -
48 hours [critical time for women with CVS disease]
▪ CO comes back to normal by 10 days
• Lactation: requires Milk Synthesis and Milk Ejection [by oxytocin]
▪ Milk Synthesis:
▪ Requires synthesis of milk secreting apparatus that is proper and
complete development of breastductules and glands
▪ Oestrogen & Progesterone are required for proper development of milk
secreting apparatus
▪ Prolactin is the major hormone required for milk synthesis
▪ Human placental lactogen [HPL], cortisol, insulin also promote milk synthesis
by prolactin
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▪ Prolactin levels increase throughout pregnancy & reaches the max level near
term but there is no actual milk synthesis during pregnancy despite of
increased levels of prolactin; it is progesterone which inhibits lactoglobulin
production
▪ What happens after delivery?
▪ Prolactin level actually decrease after delivery; so what triggers milk
synthesis:
• The 1st stimulus for milk secretion & synthesis is withdrawal of progesterone
• Mature milk comes after 3-4 days of delivery
• Initially there is secretion of colostrum
▪ For continual Secretion → Suckling is the most important stimulus
• Puerperal Fever:
▪ Defined as temp >390 C/100.40 F after 1st 24 hours of delivery
▪ Causes:
▪ Breast engorgement
▪ Mastitis
▪ Genital Infections
▪ UTI
▪ Atelectasis

▪ Breast Engorgement:
▪ Tenderness
▪ Difficulty in feeding
▪ Warm to touch
▪ Management:
• Advised to continue breast feeding
• Cold compression
• Ensure that breasts are emptied
• Analgesics
▪ Mastitis:
▪ Infection of breast
▪ Most common organism which causes infection is Staph aureus that
come from throat of infant
▪ Management:
• Antibiotic Therapy [cloxacillin/Erythromycin]
• Continue breast feeding [even from the affected breast]
▪ No C/I to breast feeding with mastitis
▪ If there is a breast abscess it leads to high grade spiking fever. The
abscess may not be fluctuant. T t→ Incision & Drainage

▪ Genital infections →Upper genital tract infection that occurs during

puerperal period is called puerperal sepsis, This puerperal sepsis can be
localised to:
▪ Uterus - Endometritis
▪ The infection spreads from the endometrium to elsewhere along the
lymphatics in the parametrial tissue. This parametrial tissue gets

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 inflamed. Infection can spread to the tubes, ovaries and pelvic
peritoneum.
▪ Most common Risk factor for devel opment of Endometritis is Route of
delivery. Endometritis is more common in C -Section than vaginal
delivery
• Other risk factors:
• Prolonged Labour
• Prolonged Leaking
• Multiple P/V examination
• C/Fs:
• Fever
• Pain Abdomen
• Foul Smelling lochia

• Per abdomen Examination:

• Tender uterus
• Subinvolution
• Per vaginal Examination:
• Forniceal Tenderness
• Most common organisms responsible for endometritis after delivery:
• Polymicrobial
• Enterococci
• Group A Streptococci
• Management: AfraTafreeh.com
• Check CBC [Hb, TLC, DLC]
• High vaginal Swab for culture sensitivity]
• Start i.v antibiotics [Clindamycin + Gentamicin]
• After starting i.v antibiotics also rule out placental retained
tissue by USG
If retained tissue +nt → Evacuation done under antibiotic cover

▪ If a woman with puerperal sepsis improves clinically but the fever

does not decreases instead becomes spiking high factor despite
antibiotics then it is because of Septic Pelvic Thrombophlebitis that
is the infected foci has gain access to uterine veins → Ovarian veins &
that has caused thrombosis in pelvic vein leading to persistent fever

▪ It can be diagnosed by Pelvic CT/MRI

▪ Tr:
• Continue Antibiotics
• Add Heparin Therapy [However, recent evidence no added
benefit in recovery of fever or prognosis).

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