OB Lecture 3 - NON–INVASIVE ANTEPARTUM FETAL

SURVEILLANCE
USTMED ’07 Sec C - AsM

Antepartum Fetal Surveillance Non- Stress Test

Definition - All methods to monitor fetal well being before labor - Basis :
Administered :  Fetus with good integration of PNS, SC , brain and
1. age of gestation when fetal survival possible autonomic NS and intact myocardium will respond
2. When neuro developmental center is already operative to FM with accelerations

Antepartum Fetal Surveillance Methods - Interpretation:

Non-Invasive
Fetal Movement Counting
Non-Stress Test
Contraction Stress Test
Biophysical Profile Scoring
Doppler Velocimetry
Fetal Movement Counting
- Simple
- Least Expensive
- Second half of pregnancy
Invasive
Amniocenteses
- Reactive – 2 FM in 20 min. , FHR accels. 15
bpm.,15 secs. , variability 6bpm. N baseline
Chorionic Villus Sampling
Fetal Blood Sampling - Non-Reactive – (-) FM, (-) acceleration w/
movement or stimulation, poor or (-)LTV, baseline
N or abn.
- Uncertain Reactivity - < 2 FM in 20 min. or accels
of < 15 bpm.,<15 secs., LTV < 6 bpm. Abn.
Baseline

- Basis :
 Compromised fetus ↓ O2 requirements by reducing
activity
 ( + ) correlation between maternal perception of
fetal movements and movements by US scanning
for 28-43 wks.
 Documented cessation of fetal activity warns of Reactive Non-reactive
impending death

- Method: - Reactive Test - good fetal well being for 1 week or

 Most attractive and convenient “ count to 10” more in > 99% of cases.
 Performed at any convenient time - Non- Reactive Test – poor fetal outcome (perinatal
 Patient Left lateral , concentrate on fetal activity death, Low 5 min. AS, late decels.) in < 20 % cases
 Evening hours, recent meal not necessary - Uncertain Reactivity- repeat NST, back-up BPS, CST
 Father help in charting promote family depending on clinical condition or OB judgement.
attachment and compliance
- Limitations of NST
- Fetal Kick Count Chart 1. Fetal Sleep State
 Contact physician if >1 hr to feel 10 movements - Fetal sleep state affects fetal
cardioregulatory center, periodic variation in
- Limitations of Fetal Movement Counting variability
1. Patient Comprehension and Convenience - Periods of quiet sleep last for 1 hr. extend
 Clear instructions mandatory observation time to eliminate possibility of
fetal sleep state
 Educational attainment and socioeconomic
- OFFSET LIMITATION
background
 “10-20-40” rule
 Problem of compliance before advent of “
- Extension to 90 min. improve false (+) rate
Count to 10 method”
- Fetal inactivity may be prolonged up to 1 hr.
2. Failure to anticipate certain stillbirths:
 No technique can anticipate stillbirths
2. DRUGS
 When FMC reassuring , still births may be due - Increase FHR
to acute hypoxic changes (abruptio placenta, Mechanism Example
umbilical cord compression)
B-adrenergic Ritodrine
3. Failure to detect growth abnormalities:
stimulation Terbulatline
- Diminished activity only in the most severe
Isoxuprine
cases of IUGR < 5h percentile
Increase Metabolic rate Caffeine, Thyroxine
( Matthew,1975)
CNS stimulants Cocaine, Ketamine
4. Failure to detect malformations:
- Most fetuses w/ congenital anomalies show Vagal Blockade Atropine
normal fetal movement patterns Paracatechol Stimulants Ephedrine
A-adrenergic blockade Phentolamine
- Fetuses w/CNS anomalies (hydrocephalus) or
restriction of the LE (congenital hip - Decrease FHR
dysplasia) ↓ FM (Rayburn, 1985) Mechanisms Example
5. Failure to distinguish bet multiple pregnancies: Vagal Stimulation/SA Digoxin
- Technique cannot distinguish between twins Myocardial depressants Lidocaine
on daily basis. B-sympathetic blockade Propanolol
- Mother cannot determine which of the CNS depressants General anesthetics
fetuses are less active.
6. Drugs
3. Maternal Conditions:
- Depressant drugs: barbiturates, - Thyrotoxicosis , Hypokalemia – baseline FHR
benzodiazepines, narcotics, methadone, variability
alcohol  ↓ FM - Maternal dehydration - ↑ FHR
- Day2 of Bethamethasone administration FM ↓ - Maternal fever - ↑ fetal core temp.; ↑ FHR
49% all values return to normal 4. Fetal Conditions:
 Day4 transient effect - Congenital Anomalies –heart block,
7. Smoking: anencephaly
- Temporary ↓ in FM 5. Gestational Age:
- Because of increased maternal - “Physiologic non-reactivity”
carboxyhemoglobin levels or direct effect of - NST in preterm infant :
nicotine on Fetal CNS  15bpm amplitude not typical
 < of organized fetal arousal states
Electronic Fetal Heart Rate Monitoring (state F) common quiet sleep states
(state 1F)
  Low amplitude decelerations seen FM Cortex-nuclei 9 wks
with FM (movement)
FB 4th ventricle 20-21
 FHR ↓ in both rest and activity
(breathing) wks
periods with↑ in AOG FHR Post. 24 wks Hypoxia
- Extend testing time and modifying criteria to (heart rate) Hypothalamus
10 bpm/accelerations reduce False (+) rate medulla
of NST.
- NICHD ,1997 Research Guidelines for
Interpretation of FHR:
 < 32 weeks –accelerations in
preterm fetus is >/= 10 bpm. , >/= - Two categories:
10 secs. 1. Acute biophysical variables:
6. Poor predictor of chronic asphyxia: - altered immediately in the presence of fetal
- non- visualization of Amniotic Fluid hypoxemia
- must be combined with BPS or AFV - FB, FT,FM, HEART RATE (NST)
measurement 2. Chronic Biophysical Variables:
- Clinical Efficacy of NST
- requires a period of time before alterations
- High False (+) Rate  80%
become visible Amniotic Fluid Volume – Fetal
- Non-Reactive Test FURTHER EVALUATION compensatory mechanism  Blood flow
(BPS , CST) directed to essential organs (Brain, Heart,
Adrenals) non-essential organ (Kidney)
Contraction Stress Test -   Amniotic Fluid Volume
- Basis:
- Marginally compromised fetus w/ limited O2
- Methodology:
reserve and limited placental function manifest
- curvilinear scanner
w/ late decelerations when subjected to uterine
- Initial survey:
contractions.
a. Fetal #,lie ,position
b. Placenta
- Methodology:
c. Fetal morphometric data ( BPD,AC,FL)
- Same with NST , 20 min. recording of FHR
d. Gen. Survey
and uterine activity.
- Fetal Tone, Fetal Movement, Breathing, AFV
- (-) Uterine contractions :
combined with NST for Full BPS , (-) NST Modified
1. IV Oxytocin 3 cxns. In 10 mins.
- Biophysical Profile Scoring
2. Nipple stimulation ( cost-effective , Variable Score 2 Score 0
shorter testing time. Fetal 30 sec. Sustained Breathing < 30 sec. Of fetal breathing
 1 nipple x 2 min. , rest 5 min. Breathing Movements movements in 30 mins.
In 30 min.
Fetal 3 or > Gross Body Movements in 2 or < gross body movements in
- Interpretation of CST Movements 30 min. 30 min.
- Negative – (-) Late decelerations or
Simultaneous limb and
Trunk movements
observation

significant variable decelerations Fetal Tone 1 episode of motion of a limb fr. Semi or full limb extension w/
Position of flexion to ext. w/ no return or slow return to
- Positive – Late decelerations ff. by 50% or > return flexion
if frequency is < 3 in 10 min. Fetal Heart FHR accels 15/bpm. Lasting for (-) accelerations or < 2
Rate 15 secs. W/ FM for 20 min. Of FHR in 20 min.
- Equivocal Suspicious – Intermittent late or AFV AF pocket 1 cm. In 2
planes
AF pocket < 1 cm. In
2 planes
significant VD present in one contraction
- Equivocal Hyperstimulatory – FHR decels. in - BPS Interpretation
cxns. > 2 min. or > 90 secs. BPS Score Interpretation Management
10 Normal Non- (-) indication for delivery weekly testing
- Unsatisfactory - < 3 cxns. In 10 min. or asphyxiated DM 2 x a week
uninterpretable trace 8/10 N AF 8/8 Normal Non- (-) indication for delivery Rpt. Test /protocol
asphyxiated
8/10 ↓ AF Chronic fetal DELIVER
asphyxia
suspect
6 Possible fetal AF abn. DELIVER
asphyxia <36 wks. N AF Cx favorable Deliver, if < 36 wks.
LS ration<2 ,Cx unfavorable , rpt.test in 24 hrs. ,
rpt. Test < Deliver
>6 Observe
4 Possible fetal Rpt.test same day < 6 deliver
asphyxia
0 to 2 Almost certain DELIVER
asphyxia

CST (+) CST (-) - Modifications in BPS

- Limitations of CST
- Same limitations as NST
- Limited application :
 Multiple Pregnancy
 Preterm Labor
 Hx. Of Uterine Rupture
 Placental Abnormalities
 Classical CS scar
- Test Reliability of CST
- (+) CST poor predictive value < 35%
- Management depend on:
1. age of gestation – Preterm , BACK-UP
BPS or Doppler. Term or Post term
DELIVER
2. Maternal Condition
Biophysical Profile Scoring
- Basis:
 Hypoxia Cascade
Fetal CNS centers
FT Cortex/subcortical 7.5-8.5
(tone) area wks
 Selective use of NST when all other 4 variables are
normal
 Substitution of AFI for vertical pocket
 NST/AFI – complete BPS for abn. NST or AFV
 BPS & Placental Grade – scoring 3 for intermediate
variable VAS
- Timing and Frequency of BPS
 Time and frequency variable Individualized
approach  “ Disease specific testing “
 Testing not started at AOG where active
intervention not possible
 More immature fetus more abnormal score to
warrant delivery
 Take into consideration maturation of CNS centers
- Limitations of BPS
1. Fetal rest activity cycles:
 Fetus variation in sleep states average 20-30
min. more pronounced with fetal maturity
Embryogenesis  REM stage – FB present 30-75% of time, apnea
pds. brief, GBM more frequent, FT diminished
  Non- REM –FB 14- 35% ,apnea pds. long so - The average interval between last normal
that if < 30 min. observation of absent FB score and fetal death was 3.62 days
may not be due to hypoxia FT increased, GBM (placental & cord accidents)
diminished
Doppler Velocimetry
2. Maternal Glucose level:
 ↑ incidence of FB after meals.
 ↑ in FB in the 2nd. & 3rd hr. after a 800kcal.
Meal during the last10 wks. of pregnancy
 No association with meals and incidence of
GBM and FT.
3. Gestational Age:
 FB seems to ↑ with advancing AOG 24-28 wks.
–14% of time , 19 wks- 6%, 10 wks- 2%
 GBM & FT – move more often at earlier AOG ,
more sporadic and shorter
4. Alcohol and Smoking:
 FB– inhibited by alcohol , 20 oz. Of alcohol in
healthy pregnant women inhibit FBM x 3hrs Doppler Shift
not reversed by glucose
 Smoking –controversial - Spectral analysis:
1. Quantification of flow – unreliable
• 2 cigarettes ↓ FB 2. Doppler wave form analysis – waveform from an
• ↓ in rate but not incidence arterial source represent arterial velocity
waveform and is configured by upstream and
• Nicotine – effect on uterine vasculature downstream circulatory factors.
causing fetal hypoxemia, direct effect
on fetal respiratory drive GBM & FT – not
affected by Smoking and Alcohol
5. Labor:
 FB – initial fall in the rate with Braxton Hicks
cxns. With ↑ after
 incidence ↓ during last 3 days prior to onset
of labor and during latent phase, abolished
during active phase
 GBM & FT – no effect
6. Drugs
↓ FBM ↑ FBM
Anesthetics Cathecolamines
Wave Form Analysis
halothane, adrenalin, B mimetics
thiopental Adenylcyclase inhibitors Arterial Venous Other
Barbiturates Prostaglandin synthetase Umbilical Ductus Venosus Coronary sinus
Narcotics – morphine inhibitors –indomethacin MCA Inferior Vena Cava Coronary arteries
Uterine Pulmonary artery
Benzodiazepines Doxapram Aorta
Prostaglandin Renal Artery
Pancuronium Internal Carotid
Artery

- Limitations of Doppler Velocimetry

Drugs – Fetal Movement 1. Use as a primary antepartum surveillance test
Drug Effect limited ( IUGR, DM,SLE, APAS )
Inhalational anesthetics Abolition of FM o ALERT signal of possibility of fetal
(Halothane) compromise associated with placental
Neuromuscular Blocking Abolition of FM pathology
Agents (pancoronium) o Utilize other tests ( BPS, NST, CST)
Narcotics Reduced FM o Beginning of a spectrum NOT a pt. Where
Neuroepileptics Variable effect morbidity appears
Steroids Transient decrease o Mean duration of Dx. Of AEDV to onset of
fetal distress 6-8 days
Drugs – Effect on FT 2 High quality equipment and trained personnel
Drug Effect 3 Inability to predict stillbirths related to acute
Neuromuscular Blocking Agents ↓ in flexor tone changes in maternal fetal status (placental and
Phenobarbital & Benzodiazepines ↓ in flexor tone cord accidents)
Narcotics to the mother (-) effect 4 Drugs:
Drug Effect
7. Polyhydramnios Terbutaline & Ritodrine ↓ S/D ratio UA, Uterine Artery
- Maternal Diseases w/ polyhydramnios (DM, MgSO4 ↓ MCA indices
Multiple Pregnancy, Hydrops) cannot be Steroids:
assessed because no score,only in Dexamethasone
oligohydramnios Betamethasone ↓ PI in MCA
8. Inability to provide an estimate of fetal reserve
- Waxing and waning of BPS parameters in - Interpretation and Management Guidelines
sustained hypoxemia indistinguishable fr. N o Umbilical Artery Doppler weekly
BPS activities. This is because of fetal o Abn. Doppler studies useful in determining
compensation & resetting of sensitivity. frequency of other tests
Sudden insult (abruptio), superimposition of o Abn. Doppler studies < 32 weeks look for other
2nd insult ( uterine cxns.)
evidences of fetal compromise
o > 32 weeks, prior to term deteriorating Doppler
- Test Reliability:
studies (AEDV, REDF) may be indication for
- Corrected Perinatal Mortality Rate: 0 – delivery.
26.4/1000 o *** Take into consideration ALL clinical factors
- False (-) rate : 0.078-2.28
- Umbilical Artery
 - CT Significant ↓
in CS for fetal
distress (-) effect
on perinatal
mortality

Umbilical Artery Flows

- Cochrane Pregnancy and Childbirth Group, 2002

- 11 RCT’s N = 7000
- HR with doppler vs. HR w/o Doppler
- Results:
• ↓ perinatal deaths (OR .71, 95%CI 0.50 – 1.01)
• fewer induction of labor (OR .83 95% CI .74-.
93)
• fewer hospital admissions (OR .56 95% CI .43
-.72)
- Conclusion:
 Use of umbilical doppler in HR pregnancies
improve outcome and reduce perinatal
deaths

Conclusion
1. Methods and Limitations
2. NO tests superior
- fin -
3. INTEGRATE whole clinical picture !! AsM