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Fetal Assessment Prof. Z. Babay. Screening for high risk pregnancy History * Age *Social burden *Smoking *Past medical conditions e.g D.M, HTN *Past Obstetric.

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Presentation on theme: "Fetal Assessment Prof. Z. Babay. Screening for high risk pregnancy History * Age *Social burden *Smoking *Past medical conditions e.g D.M, HTN *Past Obstetric."— Presentation transcript:

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 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 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

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

18

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 minFetal 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 ManagementInterpretationTest Score Result Intervention for obstetric and maternal factorsRisk 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 hrEquivocal 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 asphyxia6 of 10 (abnormal fluid) Deliver for fetal indicationsHigh probability of fetal asphyxia 4 of 10 Deliver for fetal indicationsFetal asphyxia almost certain 2 of 10 Deliver for fetal indicationsFetal asphyxia certain0 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

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41 Umbilical Artery Doppler

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43 Umbilical cord doppler

44 Reverse flow in umbilical artery

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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---1 st trimester---PAPPA& β HCG, 2 nd 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 % 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 pregnancySampling is done to the cyto-trophoblasts done between weeks of pregnancy

57

58 CVS

59 Thank you


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