1. Fetal distress Women Hospital, School of Medical, ZheJiang University Yang Xiao Fu Abnormal Liquor Volume

2. Oligohydramnios Polyhydramnios

3. Defined as amniotic fluid volume more than 2000ml at any period of gestation Incidence 0.5% - 1.6% If amniotic fluid volume increase progressively over months, the symptoms are usually milder, known as chronic polyhydramnios If amniotic fluid volume increase rapidly over days, can causse severe compression symptoms, known as acute polyhydramnios

4. Etiology Fetal anomaly Mutiple pregnancy Abnormality of placenta and umbilical cord Pregnancy complications

6. Ultrasound examination Amniotic fluid index, AFI ≥25cm Depth of largest amniotic fluid pool (amniotic fluid volume, AFV) ≥8cm AFV 8-11cm, as mild polyhydramnios AFV 12-15cm, as moderate polyhydramnios AFV ≥ 16cm, as severe polyhydramnios

7. Treatment Fetal anomaly termination of pregnancy Normal fetal indometacin amniocentesis

8. Oligohydramnios Third trimester amniotic fluid volume less than 300ml is known as oligohydramnios Incidence 0.5% - 5.5% Fetal structural deformity

9. Etiology Fetal anomaly Placenta factors Amniotic membrane abnormity Maternal factors

10. Clinical findings Fundal height Fetal movements

11. Ultrasound examination AFV ≤ 2cm AFI < 5cm 5cm < AFI < 8cm, known as suspicious oligohydramnios

12. Treatment Fetal anomaly termination of pregnancy Normal fetal expectment management termination of pregnancy

13. Fetal distress

14. Definition Fetus encountering acute or chronic hypoxia intrauterine causing threat to its life and health, is known as fetal distress Fetal distress may be acute or chronic.

15. Etiology of acute fetal distress Placenta previa, placental abruptio Inappropriate use of oxytocin: too strong, too frequent and uncoordinated uterine contraction Cord prolapse, true entanglement, torsion Shock of mother

16. Etiology of chronic fetal distress Inadequate maternal blood oxygen saturation Utero-placental vascular sclerosis, stenosis Placental pathological changes Fetal factor: severe cardiovascular deformity, all causes leading to hemolytic anemia, etc

17. Clinical presentations and diagnosis Fetal heart rate abnormality Meconium stained amniotic fluid Reduced or absent fetal movement

18. Diagnosis of acute fetal distress Fetal heart rate abnormality  early stage tacchycardia>160bpm; during severe hypoxia <110bpm  CST shows late deceleration, variable deceleration  fetal heart rate <100bpm, with frequent late decelrations indicating severe fetal hypoxia, may die intrauterine any moment

19. Late deceleration

20. Variable deceleration

21. Diagnosis of acute fetal distress Meconium stained amniotic fluid: green color, dirty, thick and little volume I degree: light green, II degree: yellowish green, dirty, III degree:brownish yellow, thick

22. Diagnosis of acute fetal distress Fetal movement: early stage frequent fetal movement, subsequently reduced to absent Fetal acidosis: fetal scalp blood analysis pH <7.2 (normal 7.25 – 7.35) PO 2 <10mmHg (normal 15 – 30mmHg) PCO 2 >60mmHg (normal 35 – 55mmHg)

23. Diagnosis of chronic fetal distress Reduced or absent fetal movement Abnormal fetal monitoring Low fetal biophysical profile scoring Fetal retardation Reduced placental function Meconium stained amniotic fluid Abnormal fetal pulse oxymetry

24. Reduced or absent fetal movement Reduced fetal movement <10 times/12hours, is an important manifestation of fetal hypoxia Usually 24 hours after absent of fetal movement fetal heart beat disappears Normal fetal movement count: 30-100 times/12hours

25. Abnormal fetal electronic monitoring NST is known as non-reactive type, during 20 minutes continuous fetal movement fetal heart rate acceleration <= 15bpm, sustaining <= 15s, baseline variability < 5bpm OCT frequent variable decelerations or late decelerations are seen

26. Low biophysical profile scoring Based on ultrasound assessment of fetal body movement, breathing movement, flexor tone, amniotic fluid volume, couple with fetal electronic monitoring NST results combined scoring (each variable score 2, total score is 10) Score <= 3 indicates fetal distress, score 4-7 suspicious fetal hypoxia

27. Fetal retardation Sustained chronic fetal hypoxia, cause fetal intrauterine growth retardation  reduced cells number in organs,  reduced organ volume,  low fetal weight  presenting as fundal height and abdominal girth being lower than 10 th percentile of the same gestational age

28. Meconium stained amniotic fluid Amnioscopy examination shows dirty amniotic fluid in light green or brownish yellow color

29. Abnormal fetal pulse oxymetry Fetal pulse oxymetry principally monitor the blood oxygen partial pressure through measuring fetal blood oxygen saturation

30. Management Acute fetal distress: emergent treatment Chronic fetal distress: management plan depends on severity of the pregnancy complications, gestational age, fetal maturity, fetal distress condition

31. Management of acute fetal distress Give oxygen: face mask or nasal prong continuous oxygen at 10L/min flow Search for cause, active management: if patient has supine hypotensive syndrome, lie the patient on left lateral position; if excessive oxytocin leading to uterine hyperstimulation, stop oxytocin immediately, use tocolytics when necessary

32. Management of acute fetal distress  Terminate pregnancy soonest possible:  Cervix not fully dilated with the following conditions, immediate caesarean section: (1)fetal heart rate 180bpm, accompanied by II degree meconium stained amniotic fluid; (2) III degree meconium stained amniotic fluid, with low amniotic fluid amount; (3) CST or OCT shows frequent late decelerations or severe variable decelerations; (4) fetal scalp blood pH <7.20

33. Management of acute fetal distress Fully dilated cervix: fetal biparietal diameter has descend below ischial spines, perform assisted vaginal delivery Prepare for newborn resuscitation

34. Management of chronic fetal distress Routine management: left lateral position, give oxygen regularly (30mins, 2-3times/day) Active treatment of pregnancy complications Terminate pregnancy: pregnancy nearing term with less fetal movement or OCT shows late decelerations, severe variable decelerations, or biophysical profile <= 3 score, caesarean is indicated

35. Management of chronic fetal distress Expectant treatment: early gestation, low chance of survival if delivered, prolong pregnancy while inducing fetal lung maturation Must explain to the family that during the process of expectant treatment, there is risk of sudden fetal death, poor placental function might affect fetal growth, poor outcome.