ASSESSMENT OF FETAL

WELLBEING , MONITORING
AND THERAPY
PRESENTOR : DR. Kavila Prabhakar
MODERATOR: DR. K. Dheepane
DEPARTMENT OF PAEDIATRICS
AVMC
DEPARTMENT OF
PAEDIATRICS

OBJECTIVES

• FETAL ACTIVITY RECORD

• HUMAN PLACENTAL LACTOGEN
• ESTRIOL
• NON STRESS TEST
• OXYTOCIN CHALLENGE TEST
• FETAL HEART RATE MONITORING
• FETAL BIOPHYSICAL PROFILE
• DOPPLER ULTRASONOGRAPHY
• PREVENTIVE FETAL THERAPY
• MEDICAL THERAPY
• SURGICAL INTERVENTIONS
The purpose of tests for fetal well being
is to identify fetuses at risk of
intrauterine compromise or death, so
that timely intervention and delivery
can be planned.
INDICATIONS: pregnancies with
increased risk for stillbirth :
• Chronic hypertension
• pregestational diabetes,
• poorly controlled gestational diabetes
• growth restriction
• advanced maternal age
• increased maternal body mass , or
vascular disease or new risk (decreased
fetal movements)
• abdominal trauma
• and vaginal bleeding are candidates for
fetal surveillance
DEPARTMENT OF
PAEDIATRICS

FETAL ACTIVITY RECORD

Count to ten:
• Mother plays an important role in checking the health of her own baby
• Involves counting the number of movements or quickening made by the baby during third
trimester of pregnancy
• Total movements should equal ten in a day
• If mother feels less than 10 movements per day for 2 consecutive days , she must report to the
doctor on the following day
DEPARTMENT OF
PAEDIATRICS

• Alternatively the mother is asked to watch for fetal movements during morning,
noon , evening, for a period of one hour each
• Total fetal count is multiplied by 4 to get a fetal movements count for 12 hrs
• But , SOGC advices that women who report decreased fetal movements (less
then 6 distinctive movements with in 2 hrs)should have complete evaluation of
maternal and fetal status including NST AND BPP
DEPARTMENT OF
PAEDIATRICS

HUMAN PLACENTAL LACTOGEN (HPL)

• HPL concentration in maternal serum increase as pregnancy advances and a

level of less than 4 microgram/ml after 30 wks of gestation is associated with
fetal jeopardy.
DEPARTMENT OF
PAEDIATRICS

ESTRIOL

• Estriol production during pregnancy progressively increases as pregnancy

advances
• Can be measured in the maternal plasma or urine
• Mean unconjugated plasma estriol increases from 6 ng/ml @28 weeks to
18ng/ml at term
• A decline of less than 30% in serial plasma estriol level or in 24 hour urine
assay is indicative of fetal distress
• Persistently low levels of plasma estriol may be seen in a mother carrying
anencephalic infant
DEPARTMENT OF
PAEDIATRICS

NON STRESS TEST

• Most common method of antepartum fetal assessment

• Relatively quick , non invasive test
• In this test fetal heart rate accelerations are studied in response to fetal
movements
• The autonomic influences mediated by the sympathetic or parasympathetic
impulses affect the fetal heart rate which shows baseline variability
DEPARTMENT OF
PAEDIATRICS

TECHNIQUE

• A transabdominal doppler ultrasonic transducer is used to record the fetal heart

rate while a tocodynamometer is applied to detect uterine contractions at the
same time
• It is carried out for 20-40 minutes
• The pregnant mother is given an event marker to mark every time the fetus
moves
• The response of the FHR to fetal movements forms the basis of NST
DEPARTMENT OF
PAEDIATRICS

INTERPRETATION

• REACTIVE :
• Normal baseline FHR (120-160 bpm)
• A reactive test is the presence of two or more accelerations that peak at 15 bpm
or more each lasting 15 seconds or more in response to fetal movement.
• NON REACTIVE:
• Baseline FHR less than 120 or greater than 160
• No fetal movements and hence no fetal accelerations over a period of 40
minutes
• Presence of decelerations
DEPARTMENT OF
PAEDIATRICS
DEPARTMENT OF
PAEDIATRICS
DEPARTMENT OF
PAEDIATRICS
DEPARTMENT OF
PAEDIATRICS

• If fetus remains non reactive after stimulation , fetus should be subjected to

OXYTOCIN CHALLENGE TEST
• A persistent flow of fetal heart rate without any variability in response to fetal
movements or uterine contractions are indicative of fetal hypoxia
DEPARTMENT OF
PAEDIATRICS

OXYTOCIN CHALLENGE TEST

• Patient is positioned in the semi-fowler position and oxytocin is delivered

intravenously by an infusion pump at an initial dose of 0.5 mU/min
• The dose is doubled after every 20 minutes to obtain at least 3 uterine
contractions in a 10 min period
• Cardiotocometer is affixed simulataneously and continuously record fetal heart
rate, uterine contractions and fetal movements
DEPARTMENT OF
PAEDIATRICS

OXYTOCIN CHALLENGE TEST

• When there is fetal hypoxia , FHR begins to decelerate 15-30 seconds after the
onset of uterine contraction , this heart rate pattern is called late deceleration or
type 2 deceleration or deceleration of uteroplacental insufficiency
• Early deceleration is beningn and may occur due to compression of fetal head
• While variable fetal heart deceleration is indicative of cord compression and
variable adverse prognosis
DEPARTMENT OF
PAEDIATRICS
DEPARTMENT OF
PAEDIATRICS

• A negative OCT is extremely reliable indicator of adequacy of uteroplacental

unit and test can be safely repeated every week
• If OCT shows persistent late deceleration the baby should be delivered , if
amniotic fluid L/S ratio is indicative of fetal maturity
• When L/S ratio is less than 2 the pregnancy should not be terminated unless
both OCT and estriol levels are indicative of compromised uteroplacental unit
DEPARTMENT OF
PAEDIATRICS

FETAL HEART RATE MONITORING

• Monitored by auscultation , doppler or electronic fetal monitoring

• EFM is performed using cardiotocograph , which is a paper record of FHR

pattern plotted simultaneously in relation to uterine activity

• NICE guidelines recommend intermittent auscultation alone for low risk

pregnancies and continuous EFM for pregnancies with higher risk
DEPARTMENT OF
PAEDIATRICS

PARAMETERS OF FHR

• A) Baseline heart rate : Normal between 110 and 160 bpm

• Baseline fetal bradycardia defined as less than 110 bpm may result from
congenital heart block associated with congenital heart malformations ,
maternal medications (beta antagonists –labetalol)or fetal acidosis
• Baseline tachycardia defined as FHR more than 160 bpm may result from a
maternal fever , infection , stimulant medications (atropine) or drugs (beta
agonists) and hyperthyroidism
DEPARTMENT OF
PAEDIATRICS

• B)BASELINE VARIABILITY:
• Reduced baseline variability may result from depression of the fetal CNS due
to fetal immaturity , hypoxia , fetal sleep
• C) ACCELERATIONS:
• FHR in response to movements are reassuring
• FHR accelerations in response to mechanical stimulation of the fetal scalp or to
vibroacoustic stimulation are also reasuuring
DEPARTMENT OF
PAEDIATRICS

• DECELERATIONS:
• Early decelerations are symmetry in shape , they are beningn , maintain good
baseline variability , more commonly seen in active labor, when the fetal head
is compressed in the pelvis, resulting in a parasympathetic effect
• Late decelerations are the result of uteroplacental insufficienct /hypoxia
worsens
• Variable decelerationms result from fetal umbilical cord compression
DEPARTMENT OF
PAEDIATRICS

FETAL BIOPHYSICAL PROFILE

• Most accurate
• Non invasive
• A combination of 5 ultrasonically monitored fetal biophysical variables i.e.,
1. Fetal posture
2. Fetal breathing movements
3. Gross body movements
4. Reactive FHR
5. Volume of amniotic fluid
DEPARTMENT OF
PAEDIATRICS
DEPARTMENT OF
PAEDIATRICS

• SCORE 10 : normal fetus but test should be repeated at weekly intervals

• SCORE 8: normal fetus with low risk of chronic asphyxia , repeat the test
weekly or twice a week in postdated and in diabetic , if oligohydramnios is
present , indication for delivery ,if baby is mature

• SCORE 6 : indicative of chronic asphyxia , repeat test after 4 to 6 hrs ,if

oligohydramnios is present ,baby should be delivered immediately
DEPARTMENT OF
PAEDIATRICS

• SCORE 4: compromised fetus and baby should be delivered immediately , if

amniotic fluid L/S ratio is >2
• SCORE 0-2: suggestive of severe degree of chronic asphyxia and baby should
be watched over an extended period of 120 minutes . If score remains <4 , the
baby should be delivered without further delay irrespective of gestational age
and pulmonary maturity
DEPARTMENT OF
PAEDIATRICS

DOPPLER ULTRASONOGRAPHY

• UMBILICAL ARTERY:
• Non invasive technique to assess placental resistance
• Healthy placenta shows good diastolic flow in the fetal umbilical artery
• Poorly functioning placenta with extensive vasospasm or infarction results in an
increased resistance to flow in umbilical artery during diastole
• Reversal of flow in diastole is seen in severe placental insufficiency
DEPARTMENT OF
PAEDIATRICS
DEPARTMENT OF
PAEDIATRICS

• MIDDLE CERBRAL ARTERY(MCA):

• Used in the assessment of a fetus that is at risk for either FGR or anemia
• Increased flow in the cerebral vessels shows early evidence of placental
compromise in late onset FGR
• Peak velocity of systolic blood flow in MCA is a useful parameter for the
detection of fetal anemia in RHD alloimmunization
• IN FGR, the cerebral circulation is preferentially perfused by reducing
resistance to blood flow (brain-sparing effect)
DEPARTMENT OF
PAEDIATRICS

• UTERINE ARTERY DOPPLER:

• For third trimester fetal assessment among woman with high risk pregnancies
• Impedance to flow in uterine arteries decreases as pregnancy advances
• Elevated uterine artery resistance indicates at 22 to 24 weeks of gestation
indicate reduced blood flow in the maternal compartment of placenta and have
been associated with FGR and perinatal death
DEPARTMENT OF
PAEDIATRICS

PREVENTIVE FETAL THERAPY

• A) ACCELERATION OF FETAL MATURATION:

• Administration of betamethasone 12 mg IM two doses 24 hr apart or dexamethasone 6mg IM
every 12 hr for 4 doses to a pregnant woman between 24 and 34 weeks of gestation at least 24
hr to 7 days before delivery enhances lung maturity and reduces the incidence and severity of
hyaline membrane disease , intraventricular hemorrhage , necrotizing enterocolitis,
retinopathy of prematurity

• Administration of phenobarbitone sodium 60 mg oral single dose at night to an RH

isoimmunized mother daily for 2 weeks before the anticipated time of delivery enhances fetal

hepatic maturity and is associated with reduced severity of neonatal hyperbilirubinemia

DEPARTMENT OF
PAEDIATRICS

• B)Prevention of fetal hemorrhage :

• Mother receiving anticonvulsants during pregnancy should be administered vit
k during last 2 weeks of pregnancy to reduce the incidence of early onset
hemorrhagic disease of newborn.
DEPARTMENT OF
PAEDIATRICS

• PREVENTION OF FETAL INFECTIONS :

• In high risk populations with invasive GROUP B STREPTOCOCCAL infection
, administer crystalline penicillin G 5 million IV followed by 2.5 million units
IV every 4 hourly till delivery.
• Alternatively , ampicillin 2 g IV loading dose followed by by 1g IV every 4 hr
till delivery is equally effective
• Baby should be delivered by elective caesarean section
• Infant should be given zidovudine 2mg/kg orally every 6 hr for 6 weeks
DEPARTMENT OF
PAEDIATRICS

• PREVENTION OF NEURAL TUBE DEFECTS:

• There is convincing evidence to suggest that periconceptional intake of folic
acid is associated with risk of NT defects
• Optimum dose of folic acid is unknown nut it would appear that 0.4mg folic
acid per day is sufficient for effective protection
• In a woman with previous birth of a child with NTD the daily prophylactic
dose of folic acid is 4 mg
DEPARTMENT OF
PAEDIATRICS

MEDICAL THERAPY

• A)Congenital adrenal hyperplasia:

• Following birth of a child afflicted with CAH subsequent pregnancies should be monitored by

CVS at 8 to 9 weeks for CAH due to 21 hydroxylase deficiency which can be diagnosed by

PCR-DNA technology

• Elevated levels of pregnendiol in the amniotic fluid is also diagnostic of CAH

DEPARTMENT OF
PAEDIATRICS

• If fetus is effected , mother should receive oral dexamethasone 1 mg daily

throughout pregnancy to prevent masculinization of female fetus
• In centres where facilities for cvs are not available when there is high risk for
birth of CAH effected child(due to birth of previously affected sibling),
maternal dexamethasone therapy should be started at 10 weeks of gestation
DEPARTMENT OF
PAEDIATRICS

• CARDIAC ARRHYTHMIAS:

• Fetal tachyrhythmia with impending CHF can be treated by oral administration

of digoxin to the mother in a dose of 0.75 to 1 mg/dl.

• Fetal cardiac decompensation by complete heart block has been succesfull
managed by administration of symopathomimetic drugs and in utero fetal
pacemaker
DEPARTMENT OF
PAEDIATRICS

• CONGENITAL HYPOTHYROIDISM:
• This is due to iodine deficiency which is totally preventable by consumption of
iodized salt or injection of depot preparation of iodine deep IM to the pregnant
woman residing in iodine deficient endemic areas
DEPARTMENT OF
PAEDIATRICS

• THROMBOCYTOPENIA:
• Mothers with active ITP should receive corticosteroid therapy during last 2
weeks of pregnancy
• In isoimmune type of fetal thrombocytopenia , transfusions of maternal
platelets , and immunoglobulins through the umbilical vessels by cordocentesis
DEPARTMENT OF
PAEDIATRICS

• THYROTOXICOSIS :
• Carbimazole or propylthiouracil therapy is advocated , if there is fetal
tachycardia
DEPARTMENT OF
PAEDIATRICS

SURGICAL INTERVENTIONS

• INTRAUTERINE BLOOD TRANSFUSION:

• Intrauterine blood transfusion is life saying to severe anemia due to RH
issomunization so that fetal gestation is enhanced till ex utero viability is
assured.
• Fetal intraperitoneal transfusions have been replaced by fetal intravascular
transfusion by cordocentesis
• Intrauterine transfusion is indicated when fetal hematocrit drops to 20-25%
DEPARTMENT OF
PAEDIATRICS

• CONGENITAL HYDROCEPHALUS:
• Fetal ventriculoamniotic shunt has been done in some rapidly progressive cases
of hydrocephalus around 20 weeks of gestation
DEPARTMENT OF
PAEDIATRICS

• CONGENITAL DIAPHRAGMATIC HERNIA :

• Despite aggressive postnatal management of infants with CDH , outcome is
unsatisfactory with high mortality due to hypoplasia of lung
DEPARTMENT OF
PAEDIATRICS

• PLEURAL EFFUSION :
• Pleuroamniotic shunt has been created in utero to relieve pleural effusion and
prevent development of hypoplasia of lung
DEPARTMENT OF
PAEDIATRICS

• CARDIOVASCULAR DISORDERS :
• Cardiac interventions like aortic valve dilatation for critical aortic stenosis
• Atrial septostomy for intact atrial septum
DEPARTMENT OF
PAEDIATRICS

THANK YOU

REFERENCE: CLOHERTY
MEHARBAN
SINGH