1330 ANTEPARTUM FETAL WELL BEING AND SURVEILLANCE

1330 ANTEPARTUM FETAL WELL BEING AND SURVEILLANCE
Class 5

Outline Screening for Fetal Health- PRE-CONCEPTION
CARRIER SCREENING/GENETIC SCREENING/ DIAGNOSIS MOTHER MONITORING MIDWIFE MONITORING FETAL WELL-BENG TESTING

PRECONCEPTION RISK ASSESSMENT MATERNAL NUTRITION PRENATAL VITAMINS
EXERCISE LIFESTYLE MATERNAL AGE FAMILY HISTORY FAMILY SUPPORT CARRIER SCREENING

CARRIER SCREENING What is carrier screening?
Carrier screening is a blood test performed on healthy adults to determine whether they carry a recessive gene mutation that could cause disease in their children. What does it mean to be a carrier? A carrier is a person who has only one copy of a gene mutation for a recessive disease. A carrier generally has no disease symptoms but risks having an affected child if her partner is also a carrier. When is carrier screening performed? Couples planning a family should ideally be screened before they conceive, or as soon as possible after conception, to allow all available reproductive options to be considered. Because advances in genetic medicine occur quickly, couples should inquire about screening options before every pregnancy.

Autosomal Recessive Cystic Fibrosis
Autosomal Recessive Cystic Fibrosis. Tay-Sachs, Thalassemia, Sickle-Cell Anemia

Cystic Fibrosis Screening
Cystic fibrosis (CF) is a life-threatening genetic disease. People with CF are prone to breathing difficulties (including lung infections and severe lung damage), digestive problems, and other complications. Some providers offer CF carrier screening to all patients. Others offer it only to those at highest risk, but anyone may request it. People at high risk include Caucasians and people who have a relative who has CF or who is known to be a carrier. According to the CF Foundation, 1 in 29 Caucasians carries an abnormal cystic fibrosis gene, compared to 1 in 46 Latinos, 1 in 65 African Americans, and 1 in 90 Asian Americans. If you opt for testing and your screening is negative, there's still a possibility your baby will have CF, but the risk is much smaller. (Many different mutations may cause cystic fibrosis, and carrier screening tests only for the most common ones.) If you do carry the trait, then your partner will be offered screening as well. Among Caucasians, the chance that both parents are carriers is 1 in 841. If you and your partner are both carriers, the odds are one in four that your baby will have CF. In this case, you may want to talk to a genetic counselor about what this means and to explore your options. If you're already pregnant, you may decide to undergo a diagnostic test such as CVS or amniocentesis to find out if your baby has CF.

Sickle Cell Screening Sickle cell disease is a debilitating red-blood-cell disorder. Depending on your family history and ethnic heritage, you may be offered a blood test to check for the genetic mutations that cause this condition. High-risk groups include people of African, Caribbean, South or Central American, Mediterranean, Indian, or Arabian descent. According to the National Institutes of Health, 1 in 12 African Americans carries the gene for this disorder. If you're a carrier, your partner will be offered testing as well. If you and your partner are both carriers (or your partner is a carrier of a related blood disorder), your baby's chance of having sickle cell disease is one in four. In this case, you may want to talk to a genetic counselor about what this means and to explore your options. If you're already pregnant, you may decide to undergo a diagnostic test such as CVS or amniocentesis to find out if your baby has sickle cell disease.

Thalassemia Screening
Thalassemia encompasses a varied group of inherited blood disorders, including some that are relatively mild and others that may cause severe anemia and other serious problems. More than 2 million people in the United States carry the genetic trait for it. High-risk groups include people of Southeast Asian, Chinese, East Indian, African, Middle Eastern, Italian, Greek, and Turkish ancestry as well as anyone with a family history of the disease or a family member who is a known carrier. People who have the thalassemia trait may have a mild form of anemia. If your initial blood count shows your red blood cells are small but your iron status is normal, further testing will be done to check for the thalassemia trait. If you're a carrier, your partner should be offered testing as well. If you're both carriers (or if your partner is a carrier for another red blood cell disorder like sickle cell disease), your baby is at high risk for the disease. In this case, you may want to talk to a genetic counselor about what this means and to explore your options. If you're already pregnant, you may decide to undergo a diagnostic test such as CVS or amniocentesis to find out if your baby is affected.

Tay-Sachs Screening Tay-Sachs is a fatal disease of the central nervous system. About 1 in 250 people in the United States carry the genetic trait for it. Among Central or Eastern European (Ashkenazi) Jews, French Canadians, and Cajuns, the carrier rate is about 1 in 27. Among Irish Americans, it's 1 in 50. You should be offered screening if you belong to any of these groups or have a family history of the disease. (Ashkenazi Jews are also at risk for carrying the genes that cause two other severe nervous system disorders, familial dysautonomia and Canavan disease, and can be screened for those and a few others as well.) If you and your partner both carry the gene for Tay-Sachs, your baby has a one in four chance of having the disease. You may want to talk to a genetic counselor about what this means and to explore your options. If you're already pregnant, you may decide to undergo a diagnostic test such as CVS or amniocentesis to find out if your baby is affected.

Reasons for Genetic Testing
(1) to enable timely medical or surgical treatment of a condition before or after birth (2) to give the parents the chance to terminate the pregnancy with the diagnosed condition, and (3) to give parents the chance to "prepare" psychologically, socially, financially, and medically for a baby with a health problem or disability, or for the likelihood of a stillbirth. Rule Chapter: 64B24-7 :(a) Genetic or congenital abnormalities or fetal chromosomal disorder: (The midwife shall refer a patient for consultation to a physician with hospital obstetrical privileges )

GENETIC TESTING

Types of Genetic Testing
SCREENING First Trimester Screening (NI) Second Trimester Screening (NI) Integrated (NI) Sequential (NI) Level II Ultrasound (NI) (?) cffDNA (NI) DIAGNOSTIC Chorionic Villi Sampling (I) Amniocentesis (I)

What are we able to find? NEURAL TUBE DEFECTS

What are we able to find? CLEFT PALATES

What are we able to find? ANEUPLOIDIES

FIRST TRIMESTER SCREENING
Noninvasive evaluation (11-14wga) that combines a maternal blood screening test with an ultrasound evaluation of the fetus to identify risk for specific chromosomal abnormalities: including Trisomy 21 (Down Syndrome) Trisomy 18 (Edwards Syndrome) 85-90% effective The blood screen measures two pregnancy related hormones: hCG and PAPP-A. The ultrasound evaluation measures fetal length (Crown Rump Length (CRL)), and thickness of an area in the fetal neck (Nuchal Translucency (NT) DOES NOT SCREEN FOR NTD!

What First Trimester Screening Does Provide
An early method of determining risk for the most common chromosome abnormalities Can be obtained at 11 weeks Screens for Trisomies 21, 18 which make up about 50% of chromosome abnormalities at birth An effective method of screening for Trisomies 18, 21 with a detection rate of 85-90% A method for effectively screening all pregnancies regardless of maternal age

What First Trimester Screening Does NOT Provide
It is NOT A DIAGNOSIS. It does NOT say the fetus has a chromosome abnormality. It does NOT say the fetus does not have a chromosome abnormality. It does NOT screen for all chromosome abnormalities Just Trisomies 18 and 21. 50% of chromosome abnormalities seen at birth are NOT looked for by this test. It does NOT screen for NTDs It does NOT screen for organ or structural abnormalities (e.g. heart, kidney, gastrointestinal, brain, lung arm, leg etc. abnormalities)

WHO should be offered First Trimester Screening
Women under the age of 35 years without a family history of genetic or chromosome problems. Based upon individual preference, the mother will then decide Not to pursue any additional information or testing or To progress to other screening tests (2nd trimester serum screening and/or targeted ultrasound) or To progress to invasive studies (amniocentesis or Chorionic Villus Sampling). Women over the age of 35 years and/or with a family history of genetic or chromosome abnormalities should have genetic counseling prior to the first trimester screening. The screening results will then increase or decrease this individual’s risks. Based upon individual preference, the mother will then decide

MATERNAL SERUM 4 (QUAD) 4 chemical markers in maternal blood:
MSAFP, hCG, unconjugated estriol, Inhibin A Offer it to everyone; enocurage “at risk” women Offered between 14-22wga, IDEAL 15-20wga MSAFP is affected by maternal age, gestational age, race, weight, # of fetuses, & diabetes 75-79% DETECTION False positives are increased with dating discrepencies F/U- genetic testing/counseling, biochemical evaluation, cffDNA, Level II u/s, NTS, amnio Tests for Trisomy 21 (Down’s), Trisomy 18 (Edward’s), and neural tube defect (Spina Bifida, ventral wall, ect) With Down’s- AFP are low, hCG are high With Edward’s- all are low With holes- AFP are very high

Table 1. Down Syndrome Detection Rates (DRs) Obtained from Various Screening Tests12
Test Name Alias Markers Included DR, %a Triple Screen Maternal Serum Screen 3 Age, AFP, hCG, uE3 ~72 Quad Screen Maternal Serum Screen 4 Age, AFP, hCG, uE3, DIA ~79 Penta Screen Maternal Serum Screen 5 Age, AFP, hCG, uE3, DIA, h-hCG ~83 a Detection rate at a 5% false-positive rate. Individuals Suitable for Testing Women in their second trimester of pregnancy (16 to 18 weeks’ gestation preferred; 14.0 to 22.9 weeks accepted, but risk of NTD not provided for samples collected prior to 15.0 weeks)

MATERNAL SERUM 5 (PENTA)
5 chemical markers in maternal blood: MSAFP, hCG, unconjugated estriol, Inhibin A, & h-hCG) Offer it to everyone; enocurage “at risk” women Offered between 14-22wga, IDEAL 15-20wga MSAFP is affected by maternal age, gestational age, race, weight, # of fetuses, & diabetes 80-83% DETECTION False positives are increased with dating discrepencies F/U- genetic testing/counseling, biochemical evaluation, cffDNA, Level II u/s, NTS, amnio Tests for Trisomy 21 (Down’s), Trisomy 18 (Edward’s), and neural tube defect (Spina Bifida, ventral wall, ect) With Down’s- AFP are low, hCG are high With Edward’s- all are low With holes- AFP are very high

Maternal Serum Screening

Cell-free fetal DNA testing (cfDNA)

Indications for Considering the Use of Cell Free Fetal DNA
Maternal age 35 years or older at delivery Fetal ultrasonographic findings indicating an increased risk of aneuploidy History of a prior pregnancy with a Trisomy Positive test result for aneuploidy, including first trimester, sequential, or integrated screen, or a maternal serum screen.

Fetal DNA circulating freely in the maternal blood stream extracted via venipuncture on the mother. 9 wga Aneuploidies, Rh factors No risk of spontaneous abortion (Amnio, CVS) Prenatal sex discernment may cause sex selection Materni-T 21,Harmony

ACOG issued the following conclusions on the use of cfDNA testing for fetal aneuploidy: The cfDNA test is expected to identify approximately 98% of cases of Down syndrome with a false-positive rate of less than 0.5% Patients at increased risk of aneuploidy can be offered the cfDNA test. The cfDNA test should only be an informed patient choice after pretest counseling occurs. Pretest counseling should indicate that the test will only screen for the common trisomies. The test should not be offered to low-risk women or women with multiple gestations. A family history should be obtained before the use of the test. A negative cfDNA test does not ensure an unaffected pregnancy. Patients with positive cfDNA tests should be referred for genetic counseling and offered invasive prenatal testing for confirmation of the test results. The cfDNA test does not replace the accuracy and diagnostic precision of prenatal testing with CVS or amniocentesis.

Future of cfDNA Identification of Preeclampsia
cffDNA concentrations were 176(pre-eclampsia) vs 75(healthy) genome equivalents/mL at 29 weeks of gestations. cffDNA concentration can be used as a screening tool. May replace more invasive tests in most circumstances

Maternity21 Plus: cfDNA

CHORIONIC VILLI SAMPLING

CHORIONIC VILLI SAMPLING
Chorionic villus sampling (CVS) is a procedure that may be performed during pregnancy to diagnose certain genetic or chromosomal disorders. CVS involves having a biopsy of the developing placenta. The chorionic villi are the tiny units that make up the placenta and have the same genetic make-up as the fetus. CVS can test for a variety of genetic conditions, such as Down syndrome, Tay Sachs disease, and cystic fibrosis. It is generally performed during the first trimester of pregnancy, at 10 to 12 weeks, and the results are available within a few days.

CVS COMPLICATIONS Miscarriage — Miscarriage can happen in any pregnancy. However, the risk of miscarriage is nearly 3 percent higher in women who have CVS compared to those who choose amniocentesis for prenatal diagnosis. Most of the risk is confined to transcervical amniocentesis. Transabdominal CVS appears to carry a fetal loss rate similar to that of amniocentesis. The overall risk is ~1%. Bleeding — It is normal to have some vaginal spotting after CVS. CVS can cause small amounts of fetal blood to be released into your bloodstream. This can potentially cause complications in future pregnancies, especially if you have an Rh negative blood type (eg, O negative). If you have an Rh negative blood type, you will be given Rhogam (Rh(D) immune globulin) after the procedure to prevent this complication. Repeat testing — Some women who have a CVS will need a repeat CVS or amniocentesis. This can happen if the results of your first test are unclear, if the cells do not grow in the laboratory, or if there was not enough tissue collected.

AMNIOCENTESIS

AMNIOCENTESIS Amniocentesis is a test done during pregnancy to get information about the fetus by sampling the amniotic fluid, which contains cells and chemicals which are fetal in origin. The most common reason for amniocentesis is to determine for sure whether a fetus has certain genetic problems, such as Down syndrome. This test is usually done between 15 and 17 weeks of pregnancy. NEURAL TUBE DEFECTS (such as spina bifida or anencephaly) BLOOD TYPE GENETIC DISORDERS FETAL INFECTION FETAL LUNG MATURITY

AMNIOCENTESIS COMPLICATIONS
Leakage of amniotic fluid — Leakage of amniotic fluid sometimes happens after amniocentesis. In most cases, there is only a small amount of fluid leakage that stops on its own within one week. In rare cases, leakage can be ongoing. If this occurs, the mother and fetus are monitored closely for signs of problems, such as infection. In these rare cases, there is an increased risk of pregnancy complications, including preterm delivery. The risk of these complications usually depends on how much fluid is left around the fetus. Injury to the fetus — There might be a very small increased risk of problems developing in the fetus because of amniocentesis. This might include clubfoot, hip dislocation, and lung problems. Talk to your doctor about these risks before having amniocentesis. Infection — If the mother has a chronic infection, like HIV or hepatitis, there is a chance that the fetus could become infected because of the amniocentesis. The risk is probably very small, but you should talk to your doctor about the risks if you have one of these infections. Miscarriage — Studies have shown that women who have amniocentesis have a small increased risk of miscarriage. Fortunately, this complication is rare. The risk of miscarriage related to amniocentesis is estimated to be 1 in 300 to 500 (0.2% to 0.3%) .

CORDOCENTESIS

CORDOCENTESIS Percutaneous Umbilical Cord Blood Sampling (PUBS) is a diagnostic test that examines blood from the fetus to detect fetal abnormalities. PUBS is similar to amniocentesis except the objective is to retrieve blood from the fetus versus amniotic fluid. PUBS is performed after 17 weeks into pregnancy. PUBS may be performed to help diagnose any of the : Malformations of the fetus Fetal infection (i.e. TORCH) Fetal platelet count in the mother Fetal anemia Isoimmunization The miscarriage rate after PUBS is about 2%. PUBS can cause infection, cramping, and bleeding

hCG TESTING QUALITATIVE hCG testing detects the presence of hCG and is routinely used to CONFIRM PREGNANCY. QUANTITATIVE hCG testing, often called beta hCG, measures the amount of hCG present in the blood. It may be ordered to help diagnose: ECTOPIC low hCG level MOLAR PREGNANCY high hCG level MISCARRIAGE low hCG level In a bout 85% of normal pregnancies, the hCG level will double every 48 – 72 hours. The hCG levels should not be used to date a pregnancy since these numbers can vary so widely

ULTRASOUND

ULTRASOUND Ultrasound is energy in the form of sound waves. The most common type of ultrasound exam is called two-dimensional (2D) ultrasound. In this type of ultrasound, a transducer sends sound waves through the body. The sound waves hit tissues, body fluids, and bones. The waves then bounce back, like echoes. The transducer receives these echoes, which are converted into images of the internal organs and—during pregnancy—the fetus. ACOG recommended that in the absence of specific indications, the optimal time for an obstetric ultrasound examination is between 18 to 20 weeks of gestation because anatomically complex organs, such as the fetal heart and brain, can be imaged with sufficient clarity to allow detection of many major malformations. Ultrasonography in pregnancy should be performed only when there is a valid medical indication. ACOG (2009) stated, "The use of either two-dimensional or three-dimensional ultrasonography only to view the fetus, obtain a picture of the fetus, or determine the fetal sex without a medical indication is inappropriate and contrary to responsible medical practice."

ULTRASOUND INDICATIONS
DATING VIABILITY NUMBER OF BABIES SCREEN FOR ANEUPLOIDY EVALUATE VAGINAL BLEEDING EVALUATE ADNEXAL, UTERINE, PELVIC MASSES R/O HYDATIDIFORM MOLE R/O ECTOPIC LOCATION OF PLACENTA POSITION OF BABY AMNIOTIC FLUID VOLUME REVIEW OF SYSTEMS GROWTH OF BABY

Components of a 1st trimester ultrasound examination
Gestational sac location and diameter (if no embryo identified) Presence or absence of a yolk sac (diameter) Presence or absence of an embryo Presence or absence of cardiac activity Crown rump length Number of embryos Amnionicity and chorionicity of multiple gestations Anatomic survey, as appropriate for gestational age* Evaluation of the uterus, adnexa, and cul-de-sac

Components of a 2nd and 3rd ultrasound examination
Presence or absence of fetal cardiac activity, fetal heart rate and rhythm Fetal number Fetal presentation Assessment of amniotic fluid volume Placental appearance and location Umbilical cord vessel number and placental insertion site, if technically possible Fetal biometry (biparietal diameter, head circumference, femoral length, abdominal circumference) Evaluation of the uterus, cervix, and adnexa when clinically appropriate Fetal anatomic survey* Presence or absence of fetal movement Evaluation of each fetus of a multiple gestation

LEVEL 1 versus LEVEL 2 ULTRASOUND
LEVEL I ULTRASOUND SCREENING DATING FHT REVIEW OF SYSTEMS IF LATE ENOUGH LEVEL II ULTRASOUND MORE SPECIFIC AND DETAILED INDICATION OF POSSIBLE ABNORMALITY READ BY PERINATOLOGIST USUALLY

FETAL MOVEMENT

FETAL MOVEMENT COUNTING

FETAL MOVEMENT Women begin feeling fetal movement (fm) typically ~14-23 Primips typically feel movement later than multips. Fetal movement counting is not reliable before ~26-28 wga. Women with risk factors should begin kick counts at 32-34 wga Women with multiple risk factors should begin kick counts at 26-28 wga, depending on clinical indications Women who experience decreased fetal movement should perform kick counts or NST and/or BPP 50% of women with a stillbirth reported that they felt a gradual decrease of fetal movements before intrauterine death,

FETAL MOVEMENT COUNTING
Fetal Movement (Kick Counts) Generally 10 movements in 2 hours considered reassuring ACOG recommends that the MOM times how long it takes her to feel 10 kicks, flutters, swishes, or rolls. If not within 2 hours, Nonstress test (NST) is appropriate Babies sleep in minute intervals

FUNDAL HEIGHT General rule: fundal height (fh) should be be equal in cm to wga, + or – 2 cm Accuracy is increased by using the same technique and practitooner. Discrepancies should call for further evaluation Exceptions: maternal obesity, multiple gestation, polyhydramnios, oligohydramnios, known growth restriction, abnormal fetal lie, low fetal station

FUNDAL HEIGHT

FETAL HEART RATE Principles of FHTs:
Normal range , listen for seconds Note baby’s baseline Abnormal: Tachycardia: fast heart rate Brachycardia: slow heart rate Irregular: arrhythmia Note any accels , decels (if contractions present, what type?) Decels: Early=head compression Variable= cord compression Late= uteroplacental insufficiency

FETAL HEART RATE

FETAL MONITORING

FETAL HEART RATE Reassuring- Non-reassuring- Accels Late decels
Variability Non-reassuring- Late decels No variability/flat Tachycardia/Bradycardia

NON-STRESS TEST (NST)

NON-STRESS TEST (NST) -HR should temporarily accel w/ fetal movement
-accels of 15bpm for 15sec Reactive:2 or more accels in 20 min period Nonreactive: lacks accels over 40 min period -loss of reactivity: acidotic, neurologically depressed or sleeping fetus -from wks 15% nonreactive in normal fetus -variables in 50%, if nonrepetitive and brief no need for intervention

NON-STRESS TEST (NST)

VIBROACCOUSTIC STIMULATION (VAS)

VIBROACCOUSTIC STIMULATION (VAS)
Acoustic stimulation of unborn babies may make tests on their wellbeing more effective. Tests on unborn babies such as ultrasound, measuring the number of movements and the heart rate are carried out to check the baby’s wellbeing. As a baby's sleep periods can alter these results by making it non‐reactive, various methods are used to wake the baby so that it can respond to the stimulus. Fetal vibroacoustic stimulation uses a hand‐held electronic device placed just above the pregnant woman's abdomen. Brief sounds are sent through the mother’s abdomen to her baby. The vibroacoustic stimulation gives the opportunity to assess how the baby responds. Exposure of the baby to the vibroacoustic stimulation is generally considered safe but it can cause vigorous fetal movements and fetal distress. This review of 12 randomised controlled trials involving 6822 mothers found that vibroacoustic stimulation improved the effectiveness of the baby's heart rate testing. However, the data on fetal distress and perinatal death were too few to draw any conclusions on safety. More research is needed to determine the optimal intensity, frequency, duration and position of the vibroacoustic stimulation and to evaluate the safety and perinatal outcomes when used with cardiotocography and other tests of fetal wellbeing.

AUSCULTATED ACCELRATION TESTS
Not a standard of care Used as an alternative to NST Listen for 6 minutes and count every other 5sec interval. Note the results on a graph. Note the baseline, any accels (an accel is FHTs up by 2 beats). One accel indicates reactivity.

CONTRACTION STRESS TEST (CST)
-3 ctx in 10 min period lasting 40 sec or longer, either spontaneous or induced w/ pitocin or nipple stimulation -nipple stimulation induces ctx in less time than oxytocin infusion -interpreted according to presence or absence of late decels Negative: no late decels or significant variables Positive: late decels following 50% or more of ctx Equivocal-suspicious: intermittent late decels or significant variables Equivocal-hyperstimulatory: decels in ctx more frequent than q 2min or lasting > 90 s long Unsatisfactory: <3 ctx in 10 min or uninterpretable tracing Contraindications: PTL or high risk of PTL, PPROM, previous classical c/s or extensive uterine surgery, known placenta previa

BIOPHYSICAL PROFILE NST
breathing movements (episode(s) of sec in 30 min) fetal movement(3 or more discrete movements in 30 min) fetal tone (one or more extension w/ return to flexion or opening/closing of hand) AFI (single vertical pocket >2cm) SCORING 8/10 or more: normal 6/10: equivocal 4/10 or less: abnormal Regardless of the composite score, if oligohydramnios is present, further evaluation is warranted

BIOPHYSICAL PROFILE

Maturation of Central Nervous System Regulatory Centers
BIOPHYSICAL PROFILE Maturation of Central Nervous System Regulatory Centers ACTIVITY WGA MATURITY Gross body movements 6 Breathing movements 12-14 FHR accelerations resulting from fetal movement 18-20 Sleep-wake cycles 18-22

Factors Affecting the Biophysical Profile
ACTIVITY FHT TONE FM FBM AFV Fetal sleep ⇓ Early gestational age (< 33 wk) Late gestational age (>42 wk) Maternal glucose ingestion — ⇑ Maternal alcohol ingestion ⇓/— ⇑/— Maternal magnesium administration Artificial rupture of membranes Premature rupture of membranes Labor

AMNIOTIC FLUID VOLUME

AMNIOTIC FLUID VOLUME The four pocket measurements are then added to calculate the AFI. Normal AFI values range from 5 to 25 cm

PLACENTAL GRADING Grade 0 : < 18 weeks : Grade I : 18 - 29 weeks :
uniform echogenicity smooth chorionic plate Grade I : weeks : occasional parenchymal calcification / hyper-echoic areas Grade II : > 30 weeks : occasional basal calcification / hyper-echoic areas may also have comma type densities at the chorionic plate. Grade III : > 39 weeks : significant basal calcification chorionic plate interrupted by indentations an early progression to a grade III placenta in concerning and is sometimes associated with placental insufficiency

PLACENTAL GRADING

MODIFIED BPP AFI NST in 2nd and 3rd trimester AF reflects urine and low volume may indicate placental dysfunction

DOPPLER VELOCIMETRY Doppler velocimetry uses ultrasound to check blood flow in the umbilical cord or between the uterus and the placenta DIASTOLIC FLOW Umbilical flow velocity waveform of a normally growing fetus has high-velocity diastolic flow. Umbilical flow velocity waveform of an intrauterine growth restricted fetus has diminished diastolic flow. Umbilical flow velocity waveform of a severely intrauterine growth restricted fetus has an absent or reversed diastolic flow.

DOPPLER VELOCIMETRY

Screening for Fetal Health- 1st Trimester
Carrier Screening Cystic Fibrosis Sickle-Cell Anemia Thalassemia Tay-Sachs Genetic Counseling Identifying risk factors (age, family hx, ob hx) Time-sensitive guidance Informed consent Genetic Screening First Trimester Screening Serum Screening Nuchal Fold Translucency CVS cfDNA

Screening for Fetal Health- 1st Trimester
D. hCG testing- Serial testing Dropping levels Molar, Multiple, Ectopic Pregnancy E. Ultrasound Viability Dating Location # Uterine anatomy Placenta location (?) Nuchal Fold Translucency

Screening for Fetal Health- 2nd Trimester
Maternal Serum Screening 1. Quad Screen 2. Penta Screen 3. AFP

Amniocentesis- testing the amniotic fluid; done under u/s; for genetic purposes done between 15-16wga Genetic test for karyotyping to identify chromosomal abnormalities & gender Can also identify holes by levels of AFP Used to monitor fetal lung maturity- by assessing S/L ratios & PG Used to monitor Rh complications- by assessing bilirubin What is amniotic fluid made of?

Cordocentesis-aka PUBS (Percutaneous Umbilical Blood Sampling) Tests fetal blood, under u/s guidance Indications are few & specific- Rh issoimunization, need for rapid karyotyping, blood gasses (IUGR), Dx of CMV or toxo, Tx for fetal disrorders Risks

Kick Counts-many ways to count FM. Start monitoring from quickening. FM is the primary evidence of fetal well-being 10 movements in 2hrs Take notice if pattern changes or frequency ↓ Normal sleep cycle What to do when they call? NST

Screening for Fetal Health- 3rd Trimester
A. Ultrasound Same as first trimester, also for- presentation, placental location, AFI, fetal anatomy, BPP Risks Benefits Indications Level I vs Level II

B. NST/Non Stress Test Indications-any time reassurance of fetal well-being is needed How performed-external monitors Reassuring/reactive NST= 2 accelerations of 15bpm for at least 15sec in a 20min period. What if not reassuring? Extend test, give juice; may attempt VAS/vibroacoustic stimulator, BPP Disadvantages- false+, fetal sleep, maternal ingestion of depressants

C. AAT/Auscultated Acceleration Test- Listen for 6 minutes and count every other 5sec interval. Note the results on a graph. Note the baseline, any accels (an accel is FHTs up by 2 beats). One accel indicates reacitivity. Can be done in clinic, with a fetascope or doppler

D. BPP/Biophysical Profile Indications- post dates, r/o IUGR, oligo/poly How performed- level II u/s & NST Elements of BPP- each element gets 2pts if normal, 0 for abnormal Fetal movement- gross body movements (acute) Fetal tone- flexion/extension (acute) Fetal breathing movements (acute) Reactive fetal heart rate (NST) (acute) Amniotic fluid volume (chronic)

BPP con’t A compromised baby will have a non-reactive NST and little to no breathing movements Cessation of movement and tone suggests more profound compromise If not reassuring, delivery is necessary

E. Modified BPP Combines NST with AFI CST/Contraction Stress Test, also called OCT/Oxytocin Challenge Test- either with nipple stim or Pitocin Works similar to an NST Accels are best Decels not good (lates are suggestive of compromise) Not used frequently G. Doppler Velocimtry Velocity of blood flow in umbilical cord Used for IUGR

1330 ANTEPARTUM FETAL WELL BEING AND SURVEILLANCE

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