Fetal surveillance

f surveillance

1. FETAL
SURVEILLANCE
By:
Kristine R. Niñonuevo-Dayao, M.D.

2. ANTEPARTUM FETAL
SURVEILLANCE

3. Antepartum Fetal Surveillance
•A succesful antenatal fetal testing program
would ideally reduce the fetal and neonatal
outcome of asphyxia
•The goal is to prevent fetal death
ACOG Guidelines on Antepartum Fetal Surveillance. 2000 Sep 1

4. What are the components of
Antepartum Fetal Surveillance?
•Fetal Movement Counting
•Non Stress Test
•Contraction Stress Test
•Biophysical Profile
•Doppler Velocimetry

5. FETAL MOVEMENT
COUNTING
Maternal perception of fetal movement
is one of the first signs of fetal life and
is regarded as a
manifestation of fetal wellbeing.
RCOG Green-top guideline 57: Reduced Fetal Movements. February 2011.

6. - Maternal perception of fetal
movements as a good predictor of
fetal health
FETAL MOVEMENT
COUNTING

7. - The optimal number of movements
and the ideal duration for counting
movements have not been
determined; however, numerous
protocols have been reported and
appear to be acceptable.
FETAL MOVEMENT
COUNTING
ACOG Guidelines on Antepartum Fetal Surveillance. 2000 Sep 1

8. By:KriNñeyNyR:i
.ñtR: Ro FETAL MOVEMENT
COUNTING
Count your baby's movements once a day, at the same time
each day:
Lie on your left side and focus on your baby's movements
You may stop counting after your baby has moved ten (10) times.
(Babies' activity levels are usually higher in the evening after
dinner.)
If your baby does not move at least ten (10) times in
two (2) hours or if there is a sudden decrease in
movement, call your doctor.

9. Reduced Fetal Movement….
•Fetal Asphyxia
•Fetal compromise
•Low apgar score
•IUFD/Stillbirth

10. NON STRESS TEST (NST)

11. RñRis:nyssi:ys:
uRs:v NON STRESS TEST
(NST)
-Combination of fetal movements and FHR acceleration
-Ability of the fetus to accelerate its Heart Rate in
response to fetal movement
- It is primarily a test of fetal condition

12. ByB:KrisKK:rsKr
tBKrn NON STRESS TEST
(NST)
Reactive:
- presence of 2 or more FHR accelerations
That peak at least 15 bpm above the baseline lasting for
15 secs Within a 20 minute period
(for fetuses >32 weeks)

13. ie R.Nñe:BKr Reactive NST

14. *** Accelerations with or without fetal movement
should be accepted
*** a 40 minute or longer tracing should be done
before concluding that there was insufficient fetal
reactivity
*** One acceleration was just as reliable as two in
predicting a healthy fetal statusie R.Nñe:BKr
Reactive NST
ACOG and AAP Recommendations 2012

15. ByB:KrisKK:rsKr
tBKrn NON STRESS TEST
(NST)
Non Reactive:
- FHR monitoring that does not meet the
criteria previously described

16. Bou:ie R.Nñe:BKr Non Reactive NST

17. - Most common explanation:
Sleep cycle in a normal fetus that is
longer than average (esp if FHR variability
continues and with decelerations) Bou:ie R.Nñe:BKr
Non Reactive NST
*** Ultrasound with BPP should be available as a back up test

18. CONTRACTION STRESS
TEST (CST)

19. vyBri-vrDyB:KrisKK:rsKr
tvKrn CONTRACTION STRESS TEST
(CST)
-a.k.a. Oxytocin Challenge Test
-A provocative test that evaluates FHR response to uterine
Activity
-Uses spontaneously occurring contractions or contractions
Induced by either IV oxytocin drip or by Maternal Nipple
Stimulation
*** At least 3 contractions in 10 minutes for evaluation to be
possible
Maternal-Fetal Medicine Principles and Practice 7
th
Ed. 32: 478

20. - Nipple Stimulation:
-Woman rubbing her nipple through her clothing for 2
minutes or until a contraction beginsvyBri-vrDyB:KrisKK:rsKr
tvKrn
CONTRACTION STRESS TEST
(CST)
-Oxytocin Use:
-Dilute IV infusion at a rate of 0.5 mU/min and doubled
Every 20 minutes until a satisfactory contraction pattern
Is established
Williams Obstetrics 24
th
Ed. Chap. 17: 1458-1459

21. No Late or significant decelerations with
at least 3 uterine contractions in 10 minutesvyBri-vrDyB:KrisKK:rsKr
tvKrn
CONTRACTION STRESS TEST
(CST)
NEGATIVE

22. Presence of Late Decelerations with at
least 50% of the contractionsvyBri-vrDyB:KrisKK:rsKr
tvKrn
CONTRACTION STRESS TEST
(CST)
POSITIVE

23. Inconsistent or occasional Late decelerations in
<50% of contractions. Repeat in 24 hours. By:KriBKsy:tnKrenntKenK
BnKR
CONTRACTION STRESS TEST
(CST)
EQUIVOCAL -
SUSPICIOUS
EQUIVOCAL -
TACHYSYSTOLE
Contractions that occur > Q2mins or lasting
longer than 90 seconds in the presence of
late decelerations
EQUIVOCAL -
UNSATISFACTORY
<3 contractions in 10 minutes or a tracing
quality that cannot be interpreted

24. By:KriBKsy:tnKrenntKenK
BnKR CONTRACTION STRESS TEST
(CST)

25. BIOPHYSICAL PROFILE
SCORING
(BPS)

26. .syNñonsBiutNryvsuetnByrs:-t
.NnR BIOPHYSICAL PROFILE SCORING
(BPS)
•Relies on the premise that multiple parameters
of well being are better predictors of outcome
than any single parameter
•Predicts the risk of fetal death in the antenatal
period
•Identifies a compromised fetus
•Comprised of 5 variables

27. .syNñonsBiutNryvsuetnByrs:-t
.NnR BIOPHYSICAL PROFILE SCORING
(BPS)
5 Variables:
1.Amniotic fluid volume
•Measured in real time
•When there is doubt, confirmed by using pulsed
doppler
•SVP >8 cm Polyhydramnios
•SVP <2 cm Oligohydramnios

28. .syNñonsBiutNryvsuetnByrs:-t
.NnR BIOPHYSICAL PROFILE SCORING
(BPS)
5 Variables:
2. Fetal Breathing Movements
•Rhythmic fetal diaphragm contractions or hiccups
lasting >30 secs
•Most easily supressed by hypoxemia
•Most episodic

29. .syNñonsBiutNryvsuetnByrs:-t
.NnR BIOPHYSICAL PROFILE SCORING
(BPS)
5 Variables:
3. & 4. Fetal Movement and Tone
•Tone:
•Evaluation is subjective but absence strongly
correlates with fetal acidosis
•Movement:
•Observed for 30 minutes
•If no movement is noted, intervention would be
based on gestational age and clinical situation

30. .syNñonsBiutNryvsuetnByrs:-t
.NnR BIOPHYSICAL PROFILE SCORING
(BPS)
5 Variables:
5. Fetal Heart Rate Reactivity / NST

31. .syNñonsBiutNryvsuetnByrs:-t
.NnR BIOPHYSICAL PROFILE SCORING
(BPS)

32. rDa,MMDApDptvDmFltKSDFmMDAmtiaa,SpcA•tm,t
.c,fgwdcaFltNS,hclDtna,SD Recommended Fetal Treatment According to
Biophysical Profile Score
Result Interpretation Recommendation
10/10 Non Asphyxiated Conservative
8/10
(normal AFV)
Non asphyxiated Conservative
8/8
(NST not performed)
Non Asphyxiated Conservative
8/10
(decreased AFV)
Chronic compensated asphyxia >37 weeks: deliver
<37 wks: serial testing, twice
weekly
6/10
(normal AFV)
Acute asphyxia possible Term: deliver
Preterm: repeat after 24hrs, if
still 6/10, deliver
6/10
(decreased AFV)
Chronic asphyxia with possible
acute
>32 wks: deliver
<32 wks: test daily
4/10
(normal AFV)
Acute Asphyxia possible Term: deliver
Preterm: rpt after 24hr if 6/10
deliver

33. rDa,MMDApDptvDmFltKSDFmMDAmtiaa,SpcA•tm,t
.c,fgwdcaFltNS,hclDtna,SD Recommended Fetal Treatment According to
Biophysical Profile Score
Result Interpretation Recommendation
4/10
(decreased AFV)
Chronic Asphyxia with acute
asphyxia likely
If >26 wks, deliver
2/10
(normal AFV)
Acute Asphyxia almost certain If >26 wks, deliver
0/10 Gross severe asphyxia If >26 wks, deliver

34. DOPPLER
ULTRASOUND

35. By::KristKnie ytRB DOPPLER ULTRASOUND
•Allows assessment of placental status
•Helps to place other testing results in context as
well as helping to determine the relative risk of
sudden fetal deterioration

36. t.NñKñoeKseinriu UMBILICAL ARTERY
•Arise from the common iliac arteries and represent
the dominant outflow of the distal aortic circulation
•Measured at the segment of the umbilical cord near
the placenta, because it has lower resistance than
at the fetal end
•Beneficial in the management of high risk
pregnancies esp in fetal growth restriction and
placental insufficiency secondary to PES

37. t.NñKñoeKseinriu UMBILICAL ARTERY
•Towards term, there is a decreasing resistance
umbilical Arteries
Taller EDV Waveforms
Low SD Ratio, PI and RI
Better Fetal Perfusion

38. t.NñKñoeKseinriu UMBILICAL ARTERY
•However in several pathologic conditions including PES
and Chronic HPN:
•Increased resistance is noted in the umbilical
arteries
Increased
intraplacental
Resistance
=
Increased Umbilical
Artery Doppler
Indices
W. Sumpaico. Obstetric and Gynecologic Ultrasound for the Practicing Clinician

39. t.NñKñoeKseinriu UMBILICAL ARTERY
•The most prognostic feature of Umbilical Artery is
the END DIASTOLIC FLOW
Therefore Absent Flow and Reversed Flow
represent progressively ominous findings
*** AEDV at >34 weeks gestation is an indication for
delivery
*** <34 weeks with AEDV, more frequent fetal
surveillance can be done first to be able to supply
steroids for lung maturation
*** REDV is an unstable clinical state, that may
precede fetal death from hours to days
Maternal-Fetal Medicine Principles and Practice 7
th
Ed. 32: 478

40. .ñBBKrsorirNieKseinriu MIDDLE CEREBRAL ARTERY
•A transverse view of the brain is obtained at the
level of the BPD. The transducer is then moved
towards the base of the skull
•The MCA is seen as the major branch of the circle
of Willis running anterolaterally
•Most commonly reported in terms of PI values

41. .ñBBKrsorirNieKseinriu MIDDLE CEREBRAL ARTERY
•CPR (cerebroplacental Ratio) computed as:
•MCA/Umbilical artery PI
1. CPR <1 indicative of brain sparing effect
2. sudden restoration of MCA PI to normal or
increasing CPR from a previously normal serial
determination signifies Brain Sparing effect
W. Sumpaico. Obstetric and Gynecologic Ultrasound for the Practicing Clinician

42. Btont svrRy t DUCTUS VENOSUS
•Shunts blood from the proximal umbilical vein
toward the IVC at its connection to the Right atrium
•Ductus venosus velocimetry was reported to have
the best predictor of perinatal outcome
(Billardo and colleagues, 2004)
Maternal-Fetal medicine Principles and Guidelines 7
th
Ed. Chap 32: 483

43. Btont svrRy t DUCTUS VENOSUS
•The high velocity flow through the ductus venosus
makes it easier to identify with color flow doppler
imaging
•Only the ductus venosus can actively dilate with
hypoxemia, an added benefit that supports its use
•These factors and the ease of identification
throughout gestation make the ductus venosus the
precordial vein of choice
Maternal-Fetal medicine Principles and Guidelines 7
th
Ed. Chap 32: 483