1. Fetal Assessment
Prof. Z. Babay

2. Screening for high risk pregnancy
History
* Age
*Social burden
*Smoking
*Past medical conditions e.g D.M, HTN
*Past Obstetric history

3. Fetal assessment
Aim: Ensure fetal wellbeing ( Identify patients at risk of fetal asphyxia)
To prevent prenatal mortality & morbidity

4. When to start fetal Assessment
** Risk assessed individually
**For D.M. fetal assessment should start from 32 weeks onward if uncomplicated
***If complicated D.M. start at 24 weeks onward
**For Post date pregnancy start at 40 weeks
**For any patient with decrease fetal movement start immediately
** Fetal assessment is done once or twice weekly

5. FETAL AND NEONATAL COMPLICATIONS OF ANTEPARTUM ASPHYXIA
Fetal Outcomes Neonatal Outcomes
Stillbirth Mortality
Metabolic acidosis at birth Metabolic acidosis
Hypoxic renal damage
Necrotizing enterocolitis
Intracranial haemorrhage
Seizures
Cerebral palsy

6. Small for gestational age fetus Decreased fetal movement
CONDITIONS ASSOCIATED WITH INCREASED
PERINATAL MORBIDITY/MORTALITY WHERE
ANTENATAL FETAL TESTING
MAY HAVE AN IMPACT
Small for gestational age fetus
Decreased fetal movement
Postdates pregnancy (>294 days)
Pre-eclampsia/chronic hypertension
Pre-pregnancy diabetes
Insulin requiring gestational diabetes
Preterm premature rupture of membranes
Chronic (stable) abruption

7. Fetal Assessment Fetal movement counting Non stress test
Contraction stress test
Ultrasound fetal assessment
Umbilical Doppler Velocimetry

8. Fetal movement counting
Cardiff technique:
*Done in the morning, patient should
*calculate how long it takes to have 10 fetal movement
**10 movements should be appreciated in 12 hours

9. Fetal movement counting
Sadovsky technique:
-For one hour after meal the woman should lie down and concentrate on fetal movement
-4 movement should be felt in one hour
-If not , she should count for another hour
-If after 2 hours four movements are not felt, she should have fetal monitoring

10. Non stress test
*Done using the cardiotocometry with the patient in left lateral position
**Record for 20 minutes

11. Non stress test *The base line 120-160 beats/minute *Reactive:
At least two accelerations from base line of 15 bpm for at least 15 sec within 20 minutes
Non reactive:
No acceleration after 20 minutes- proceed for another 20 minutes

12. Non stress test
If non reactive in 40 minutes---proceed for contraction stress test or biophysical profile
The positive predictive value of NST to predict fetal acidosis at birth is 44%

13. NST

14. NST

15. Contraction stress test
Fetal response to induced stress of uterine contraction and relative placental insufficiency
Should not be used in patients at risk of preterm labor or placenta previa
Should be proceeded by NST

16. Contraction stress test
Contraction is initiated by nipple stimulation or by oxytocin I.V.
The objective is 3 contractions in 10 minutes
If late deceleration occur-----positive CST

17. Interpretation of CTG Normal Baseline FHR 110–160 bpm
– Moderate bradycardia 100–109 bpm
– Moderate tachycardia 161–180 bpm
– Abnormal bradycardia < 100 bpm
– Abnormal tachycardia > 180 bpm

19. Acceleration

20. Deceleration EARLY : Head compression LATE : U-P Insufficiency
VARIABLE : Cord compression
Primary CNS dysfunction

21. Early deceleration

22. Late deceleration

23. Variable Deceleration

24. Reduced Variability

25. Tachycardia Hypoxia Chorioamnionitis Maternal fever B-Mimetic drugs Fetal anaemia,sepsis,ht failure,arrhythmias

26. Ultrasound fetal assessment
Assessment of growth
Biophysical profile (BPP)

27. Assessment of fetal growth by ultrasound
Biometry:
Biparietal diameter (BPD)
Abdominal Circumference (AC)
Femur Length (FL)
Head Circumference (HC)
Amniotic fluid
Placental localization

28. BPD

29. BPD & HC

30. Abdominal circumference

31. FL

32. Growth chart

33. Placental localization

34. Placenta previa

35. Amniotic fluid

36. Fetal Biophysical profile
Abnormal (score= 0)
Normal (score=2)
Biophysical Variable
Absent FBM or no episode >30 s in 30 min
1 episode FBM of at least 30 s duration in 30 min
Fetal breathing movements
2 or fewer body/limb movements in 30 min
3 discrete body/limb movements in 30 min
Fetal movements
Either slow extension with return to partial flexion or movement of limb in full extension Absent fetal movement
1 episode of active extension with return to flexion of fetal limb(s) or trunk. Opening and closing of the hand considered normal tone
Fetal tone
Either no AF pockets or a pocket<2 cm in 2 perpendicular planes
1 pocket of AF that measures at least 2 cm in 2 perpendicular planes
Amniotic fluid volume

37. Management Interpretation Test Score Result
Intervention for obstetric and maternal factors
Risk of fetal asphyxia extremely rare
10 of 10
8 of 10 (normal fluid)
8 of 8 (NST not done)
Determine that there is functioning renal tissue and intact membranes. If so, delivery of the term fetus is indicated. In the preterm fetus less than 34 weeks, intensive surveillance may be
preferred to maximize fetal maturity.
Probable chronic fetal compromise
8 of 10 (abnormal fluid)
Repeat test within 24 hr
Equivocal test, possible
fetal asphyxia
6 of 10 (normal fluid)
Delivery of the term fetus. In the preterm fetus less than 34 weeks, intensive surveillance may be preferred to maximize fetal maturity
Probable fetal asphyxia
6 of 10 (abnormal fluid)
Deliver for fetal indications
High probability of fetal asphyxia
4 of 10
Fetal asphyxia almost certain
2 of 10
Fetal asphyxia certain
0 of 10

38. Umbilical Doppler Velocimetry
Indication:
IUGR
PET
D.M.
Any high risk pregnancy
Use a free loop of umbilical cord to measure blood flow in it

39. Umbilical cord

41. Umbilical Artery Doppler

43. Umbilical cord doppler

44. Reverse flow in umbilical artery

46. Management of abnormal Doppler
Depends on:
fetal maturity
gestational age
Obstetric history

47. Management of Doppler results
Reverse flow or absent end diastolic flow--- Immediate delivery
High resistance index---- repeat in few days or delivery
Normal flow---- repeat in 2 week if indicated

48. Assessment for chromosomal abnormality
Ultrasound
Amniocentesis
Chorionic villus sampling

49. Assessment for chromosomal abnormality
General Facts:
The general incidence of Down is 1:1000
The risk by maternal age:
at the age of :365
at the age of :109
at the age of :32
Risk of recurrence is 1% ( 0.75% higher than maternal age related risk
** In case of parental aneuploidy % risk of Trisomy in offspring

50. Methods available for screening for chromosomal abnormality
Maternal age
Biochemical---1st trimester---PAPPA&β HCG,
2nd trimester---Triple & quadriple Test
Ultrasound NT + Other markers
Fetal DNA

51. Ultrasound screening for chromosomal abnormality
Nuchal translucency(N.T)
Skin fold thickness behind the fetal cervical spine
Timing: days weeks of pregnancy
75-80% of trisomy 21
5-10% normal karyotype ( but could be associated with cardiac defects, diaphragmatic hernia, Exomphalos)

52. Nuchal translucency

53. Amniocentesis
Obtaining a sample of amniotic fluid surrounding the fetus during pregnancy.”
Indications:
Diagnostic (at weeks)
Therapeutic( at any time)

54. Indications of amniocentesis:
Genetic amniocentesis:
Chromosomal analysis (Down syndrome)
Spina bifida (Alpha fetoprotein)
Inherited diseases (muscular dystrophy)
Bilirubin level in isoimmunization
Fetal lung maturation (L/S ratio)
Theraputic amniocentesis:
Reduce maternal stress in polyhydramnios
Mainly in twin-twin transfusion or if abnormality associated

55. Amniocentesis

56. Chorionic villus sampling
Sampling is done to the cyto-trophoblasts done between weeks of pregnancy

58. CVS

59. Thank you