1. Dr Kirtan Krishna MS , DNB, Fellowship in Fetal Medicine
Assistant Professor, OBG - PESIMSR , Kuppam
Consultant Fetal Medicine – Cloud 9 hospitals, Bangalore

2. ANTEPARTUM fetal surveillance
Dr. Kirtan Krishna

3. Highlights Prolonged pregnancy Decreased fetal movements
Hypertension in pregnancy
Diabetes in pregnancy
Fetal growth restriction
Multiple gestation
PPROM
Previous LSCS
Obstetric cholestasis
Sickle cell disease
ECV
Cord prolapse

4. PROLONGED PREGNANCY
In low risk women usually induction of labour is done at 41 weeks of gestation.
When will you start antepartum fetal surveillance?
No need of any antenatal fetal surveillance before 41 weeks of gestation provided she is feeling the fetal movements well and clinical assessment of liquor volume is adequate and no risk factors

5. Suppose she declines induction of labour at 41 weeks
Suppose she declines induction of labour at 41 weeks. When will you initiate fetal surveillance?
Fetal surveillance is initiated between 41 and 42 weeks because of evidence that perinatal morbidity and mortality increase as gestational age advances.
How often will you do it?
Twice weekly modified BPP (AFI , NST)after 41 weeks.
(ACOG and RCOG – Grade C recommendation)

6. DECREASED FETAL MOVEMENTS
After fetal viability (28wks), confirm history
Lie on left side &concentrate on fetal movements for 2 hrs
<10 discrete movements in 2 hrs+risk factors for still birth – abdominal palpation, assessment of size, auscultation of FHR
CTG for 20min - Normal with no risk factors -
reassurance

7. If any abnormality on CTG/ RFM persists + risk factors for FGR/stillbirth
USG within 24 hrs – biometry +morphology + dopplers
56% of women with a high-risk pregnancy who reported RFM had an abnormal CTG.This was associated with an unfavourable perinatal outcome.

8. HYPERTENSION IN PREGNANCY
Chronic hypertension :
Growth scan with Dopplers (umblical artery) at 28 – 30 wks & 32 – 34 wks. If normal need not repeat after 34 wks.
CTG only if fetal activity is abnormal.

9. Mild or moderate gestational hypertension
Growth & umblical artery doppler if diagnosis less than 34 wks. After 34 wks only if clinically indicated
CTG only if fetal activity is abnormal

10. Severe Gestational Hypertension Or Pre-eclampsia:
CTG at the time of diagnosis
If conservative management planned – fetal growth & umblical artery doppler
do not repeat more than every 2 weeks
Repeat CTG weekly unless the results of all fetal monitoring indicate more frequent CTG or any of the following occur:
the woman reports a change in fetal movement
vaginal bleeding
abdominal pain
deterioration in maternal condition.

11. Women at high risk of pre-eclampsia :
Fetal growth & umblical artery doppler starting at 28 – 30 wks or atleast 2 weeks prior to previous onset if earlier than 28 wks.
Repeat 4 wks later in women with
Severe pre eclampsia
pre eclampsia that needed birth before 34 wks
Pre eclampsia with baby weight <10th centile
IUD
Placental abruption
Cardiotocography only if fetal activity is abnormal

12. DIABETES IN PREGNANCY
Initiate fetal surveillance ( growth & AFI) at 28 weeks provided there is no fetal growth restriction.
Repeat every 4 wks until 36 weeks if normal
No role for doppler & BPP if no growth restriction
Offer CTG from 38 wks
Repeat CTG weekly unless the results of all fetal monitoring indicate more frequent CTG until the time of termination of pregnancy

13. FETAL GROWTH RESTRICTION

15. TWIN GESTATION Uncomplicated Dichorionic pregnancy
Scan every 4 weeks from 20 weeks - Fetal growth, AFI, doppler
Uncomplicated Monochorionic twins
Every 2 weeks from 16 weeks – fetal growth, DVP, UA doppler- for TTTS
20 wks - anatomy, biometry, DVP, UA-PI , MCA – PSV (for TAPS), cervical length
22 wks onwards - fetal growth , DVP, UA - PI, MCA - PSV
Complicated – scans more often depending on the condition & severity
Dichorionic twins – no increased risk of anomalies 1 in 25
Monochorionic – 2-3 times higher risk than singleton (1 in 15 – MCDA, 1 in 6 in MCMA)
sFGR – EFW <10th centile or growth discordancy >25%`

16. Dichorionic Diamniotic Twins
CTG weekly from 38 weeks
Monochorionic Diamniotic Twins
-CTG weekly from 37 weeks
Monochorionic Monoamniotic Twins
If concerns about significant cord entanglement consider -CTGs 3 x weekly (Monday, Wednesday and Friday)
If no concerns about cord entanglement -weekly CTGs after 28 wks

17. PPROM
Scan for AFI
Women should be observed for signs of clinical chorioamnionitis.
CTG is useful and indeed fetal tachycardia is used in the definition of clinical chorioamnionitis.
CTG does not improve the outcome of preterm labour

18. PREVIOUS LSCS No role for antepartum fetal surveillance
No antepartum CTG is recommended unless fetal activity is abnormal or she experiences scar tenderness.

19. OBSTETRIC CHOLESTASIS
Women should be informed that the case for intervention (after 37+0 weeks of gestation) may be stronger in those with more severe biochemical abnormality (transaminases and bile acids).
Women should be informed of the inability to predict stillbirth if the pregnancy continues.
No specific method of antenatal fetal monitoring for prediction of fetal death
Ultrasound & CTG are not reliable methods for preventing fetal death
Continuous CTG monitoring in labour

20. SICKLE CELL DISEASE
Growth scan every 4 weeks from 24 weeks for early detection of FGR
Offer fetal monitoring if the woman declines delivery by 40 weeks of gestation.
Twice weekly assessment of amniotic fluid and a NST from 40 weeks of gestation.

21. ECV
ECV should be performed with ultrasound to enable fetal heart rate visualisation, cardiotocography and theatre facilities are available.
Cardiotocography should be performed after the procedure.

22. CORD PROLAPSE
Suspicious or pathological fetal heart rate pattern - category 1 caesarean section should be performed with the aim of achieving birth within 30 minutes or less without compromising maternal safety.
Normal fetal heart rate pattern - category 2 caesarean birth can be considered with the aim of achieving birth within 75 minutes or less - but continuous assessment of the fetal heart trace is essential, if the cardiotocograph (CTG) becomes abnormal, re-categorisation to category 1 birth should immediately be considered.