Antepartum Fetal Surveillance

Fetal Assessment The primary goal - avoidance of intrauterine fetal death Cornerstone of this assessment is to prevent fetal hypoxemia and acidemia routine prenatal care populations with an increased risk of fetal demise

HIGH-RISK PREGNANCIES

1. FETAL Anatomic anomaly Decreased fetal movement Heart block Intraamniotic infection Intrauterine growth restriction Multiple gestation Oligohydramnios

2. MATERNAL-FETAL
Abruptio placenta Abnormal serum screening (low PAPP-A, high MSAFP) Placenta previa, vasa previa Postterm or postdates,premature rupture of fetal membranes Threatened preterm delivery

3. MATERNAL
Advanced maternal age Cardiac disease (severe) GDM Hypertension, chronic Hypertension, gestational Substance abuse Systemic lupus erythematosis Thyroid disease Thrombophilia or thromboembolic disease

ASSESSMENTS FOR LOW-RISK PREGNANCIES

USG: Dating scan 1st trimester-Done as early as possible determination of fetal number fetal viability fetal position gestational age placental location amniotic fluid volume presence or absence of a maternal pelvic mass presence of gross fetal malformations

2nd Trimester USG

Fetal anatomic screening specifically at 18 to 20 weeks gestation, when visualization of the anatomic features is adequate. identify sonographic markers of fetal aneuploidy

SONOGRAPHIC GUIDANCE
for an invasive procedure as amniocentesis

FETAL MOVEMENT COUNTING

Quickening 16-22 wks Fetal hypoxemia is typically associated with a reduction in fetal activity Usually after a meal when the fetus is more active, if 10 movements are not detected in 1 hour, further testing is often recommended Costeffective first line screening test
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FETAL ASSESSMENT IN HIGH-RISK PREGNANCIES

1. 2. 3. 4. 5. 6. 7. 8. CARDIOTOCOGRAPHY NONSTRESS TEST CONTRACTION STRESS TEST ULTRASOUND GROWTH ASSESSMENT AMNIOTIC FLUID ASSESSMENT BIOPHYSICAL PROFILE DOPPLER

CARDIOTOCOGRAPHY
Principle: fetal neurologic system, through its afferent and efferent networks, serves as a key mediator to demonstrate fetal well-being 3 basic elements

Term

Characteristic

Description

Baseline

Definition

Mean fetal heart rate, rounded to increments of 5 beats/min (e.g. 140, 145); <110 beats per minute

Bradycardia

Tachycardia

>160 beats per minute

Term

Characteristic

Description

Variability

Definition

Fluctuations of the baseline heart rate;

Absent

Undetectable

Minimal

Undetectable to 5 beats/min

Moderate

6-25 beats/min

Marked

>25 beats/min

Term
Acceleration

Characteristic
Definition

Description
Abrupt increase 15 beats/min lasting 15 s

Prolonged

2 min and <10 min (10 min is a baseline change)

Term
Deceleration

Characteristic
Definition

Description
Decreases in the fetal heart rate

Early Late

Gradual decrease onset to nadir 30 s with contraction Gradual decrease onset to nadir 30 s; nadir of deceleration occurring after peak of contraction

NST
A normal NST : def: REACTIVE NST A 20-minute fetal heart rate tracing that contains two heart rate accelerations lasting 15 seconds or longer that peak 15 beats or more above the baseline If abnormal extended upto 20-40 min A nonreactive NST or an NST with specific abnormalities (e.g., high or low baseline, decelerations) should be followed by a BPP

CONTRACTION STRESS TEST

CST assesses the fetal heart rate response in the presence of contractions improves on the specificity and sensitivity of the NST by assessing the fetal response to stress.

ULTRASOUND
Fetal echocardiography at 20 to 22 weeks gestation in all pregnancies at high-risk of a fetal cardiac malformation Dm, drug, cardiac lesion, in vitro fertilisartion

3D ULTRASOUND
Surface rendering mode craniofacial anomalies, intracranial
lesions, spinal anomalies,ventral wall defects, and fetal tumors

In early pregnancy:
more accurate measurements of the gestational sac, yolk sac, and crown-rump length more accurate midsagittal view of the fetus for measuring nuchal translucency.

To measure tissue volume:

cervical insufficiency. measurement of placental volume in the first trimester may predict fetuses at risk of intrauterine growth restriction

GROWTH ASSESSMENT
Four separate leopold maneuvers Uterus can be palpated above the pelvic brim at approximately 12 weeks gestation. Thereafter, fundal height should increase by approximately 1 cm per week, reaching the level of the umbilicus at 20 to 22 weeks gestation. Between 20 and 32 weeks gestation, the fundal height (in centimeters, from the superior edge of the pubic symphysis) is approximately equal to the gestational age (in weeks) BPD gest age assessment in 2nd & 3rd trimester

AMNIOTIC FLUID ASSESSMENT

AFI
semiquantitative method <5 / >20

Maximum vertical pocket

semiquantitative method <2 / >10

FETAL ASSESSMENT IN HIGH-RISK PREGNANCIES

1. 2. 3. 4. 5. 6. 7. 8. CARDIOTOCOGRAPHY NONSTRESS TEST CONTRACTION STRESS TEST ULTRASOUND GROWTH ASSESSMENT AMNIOTIC FLUID ASSESSMENT BIOPHYSICAL PROFILE DOPPLER

Element Breathing

Criterion 1 episode of breathing movements lasting 30 seconds 3 discrete body or limb movements

Movement

Tone Amniotic fluid

1 episode of active extension and flexion of limbs or trunk 1 pocket of amniotic fluid measuring 2 cm in two perpendicular planes

Nonstress test

2 fetal heart rate accelerations lasting 15 seconds over 20 minutes

Order of appearance
Fetal tone appears at 7.5 to 8.5 weeks, Fetal movement at 9 weeks, Fetal breathing at 20 to 22 weeks, FHR reactivity at 24 to 28 weeks gestation

FETAL ASSESSMENT IN HIGH-RISK PREGNANCIES

1. 2. 3. 4. 5. 6. 7. 8. CARDIOTOCOGRAPHY NONSTRESS TEST CONTRACTION STRESS TEST ULTRASOUND GROWTH ASSESSMENT AMNIOTIC FLUID ASSESSMENT BIOPHYSICAL PROFILE DOPPLER

 Decreased diastolic flow suggests increased placental vascular resistance and fetal compromise. Severely abnormal umbilical artery doppler velocimetry (defined as absent or reversed diastolic flow) is an especially ominous observation and is associated with poor perinatal outcome,

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