Foetal Monitoring

1. PRINCIPLES OF FETAL MONITORING Mohd Hanafi Ramlee

2. I’M SORRY, I CAN’T INTERPRET SOME OF THE PICTURE HERE!!! BUT I’LL TRY MY BEST!!!

3. AIMS OF FETAL MONITORING Assessment of fetal well-being especially in high-risk mother Assessments of fetal growth Identification of fetal abnormalities and condition in all stages of pregnancy Determination of gestational period To ensure a safe delivery

4. Antenatal monitoring Labour monitoring

5. WEIGHT GAIN Cheap and simple method  using weighing machine Mother should gain 0.5 kg/week during 2 nd and early 3 rd trimester  then, the rate of weight gain is plateaus off ↓ : possibilities of IUGR, persistent nausea and vomiting or forced dieting ↑: PIH, renal disease and polyhydramnios .

6. SYMPHYSIOFUNDAL HEIGHT At least 2 times weekly The centimeters should roughly correspond to the period of gestation ↑: polyhydramnios ↓: oligohydramnios

7. FETAL KICK CHART Commonest methods – Cardiff ‘count to ten’ Start count at 9am every morning Record the time taken for baby to move 10 times Normal fetal activity-little variation in time taken ↓ fetal activity [fetal compromise] - delay in time taken Benefit: detection of fetal compromise, more easier and cheap Limitation: Maternal anxiety is common, unsure of movement, is a crude guide and sometimes inconsistent

8. A FAVOURABLE FETAL MOVEMENT CHART Day Time ( am/pm)) Patient’s Name

9. AN UNFAVOURABLE FETAL MOVEMENT CHART Day Time ( am/pm)) Patient’s Name

10. DIAGNOSTIC ULTRASOUND SCAN - 2 dimensional map of content of uterus. - Image constantly updated in real time and fetal cardiac and other movement can be studied. - < 12 weeks usage of transvaginal transducer . - > 12 weeks usage of abdominal transducer . - Good image depend on operator skill. - Disadvantages : Bio effects on cells, inducing heating.

11. transvaginal -TRANDUCER - abdominal

12. Early Problems Age Assessment Symmetry Measurement Weight Growth Anatomy Morphology Location Umbilical Cord Abnormalities Amniotic Fluid Volume Invasive Procedure

13. EARLY PREGNANCY PROBLEMS - transvaginal ultrasound role in diagnosis of disorder in early pregnancy. E.g. miscarriage - fetus present, absent fetal heart E.g. ectopic pregnancy - absent of gestational sac within uterus

14. FETAL MEASUREMENTS

15. FETAL MEASUREMENT Common = relatively ‘spared’ in growth restriction Sensitive = organ that are sensitive to changes to any factor that cause IUGR [liver/spleen]

16. CROWN-RUMP LENGTH

17. CROWN-RUMP LENGTH Geatational sac Yolk sac Fetal pole

18. BPD, HC LENGTH Biparietal diameter Head circumference

19. BPD, HC LENGTH

20. FEMUR LENGTH Femur length

21. FEMUR LENGTH

22. ABDOMINAL CIRCUMFERENCE Abdominal Circumference

23. GESTATIONAL AGE ASSESSMENT CRL/BPD  these measurements are plotted on the normogram Predictions of gestational age by ultrasound scan before 20 weeks is more accurate than predictions from last menstrual period. Measurements are done at least 2 week apart Measurements are plotted in centile -charts against a normogram

24. MEASUREMENT ON FETAL GROWTH CHART

25. Consistent growth of Small fetus

26. Slowed growth— fetal compromise

27. FETAL SYMMETRY ↑HC: Hydrocephalus ↓HC: Microcephaly ↓FL: constitutional short stature, achondroplasia ↑AC: Diabetic pregnancy, ↓AC: triploidy / trisomy 18 Asymmetry: IUGR

28. PLACENTA Transvaginal scan: if the placenta covers the internal os  major placenta praevia Mid pregnancy scan  low-lying placenta 3 rd pregnancy scan  minor placenta praevia

29. OTHERS CONDITION Amniotic Fluid scan: commonly base on AFI [if <2cm: Oligohydramnious , >7cm: Polyhdramnious ] Umbilical Cord: scan with colour doppler [ Nuchal displacement: common event associated with fetal distress] Invasive procedure: amniocentesis, chorion villus sampling, cordocentesis , fetal bladder shunt therapy, fetoscopy and endoscope.

30. AIMS OF ROUTINE ULTRASOUND SCAN

31. Magnetic Resonance Imaging: useful when i ) US images are not diagnostic or ii) suboptimal because of maternal obesity

32. MRI

33. 39 AMNIOTIC FLUID Produce : Kidneys & Lungs Remove : Fetal swallowing and blood Functions : Prevent mechanical injury, permit movement and lung development 4 quadrant method (R/L hypocondrium R/L illiac fossa )

34. AMNIOTIC FLUID INDEX Liquor volume reflects the placental size, placental function and fetal metabolism Sum of all the maximum vertical pool of liquor from the 4 quadrant of the uterus In 3 rd tri, normal AFI should be between 10 and 25cm AFI -below 5cm - oligohydramnios above 25cm - polyhydramnios

35. DOPPLER ULTRASOUND Measuring blood velocity in umbilical artery of fetus. Recorded in waveform pattern : Systolic - blood velocity speeds up. Diastolic - blood velocity slows down (depending amount resistant in arterial bed in placenta).

36. Doppler Umbilical Artery Waveforms Measure blood velocity in umbilical artery of fetus Recorded in waveform pattern showing a systolic & diastolic component During normal fetal life, diastolic flow in the umbilical artery ↑ gradually (placental resistance falls ) with gestation In placental damage/insufficiency- absent/reversed end diastolic flow which leads to fetal distress and intrauterine death.

37. Doppler Uterine Artery Waveforms Assessment of uterine artery waveforms at 24 th weeks’ gestation. Benefits: Even at absence of risk factors, severely abnormal waveforms identify 75% of pregnancies at risk of adverse neonatal outcome in early 3 rd trimester. Limitations: Less effective at prediction of later problems.

38. Principles of Fetal Monitoring 49 Cardiotocograph (CTG) Computerized tracing of fetal heart rate pattern Sensitive Reflects physiological and pathological changes

39. Principles of Fetal Monitoring 50 CTG Parameters: Baseline heart rate : Normally 110 – 160bpm <110 bpm = bradycardia >160 bpm = tachycardia

40. Principles of Fetal Monitoring 51 Baseline variability : Reflects normal fetal autonomic nervous system. Modified by : Fetal sleep states and activity. Hypoxia. Fetal infection. Drugs e.g. opioids and hypnotics (reduce baseline variability). Baseline variability – 8 bpm and 2-6 times in a minute.

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42. Principles of Fetal Monitoring 53 Fetal heart rate (FHR) acceleration. Increased baseline FHR at least 15 bpm lasting at least 15 seconds. Within 20 – 30 minutes CTG, 2 or more accelerations present define as reactive trace. Importance – fetal hypoxia

43. Principles of Fetal Monitoring 54 FHR deceleration Transient reduction fetal heart rate of 15 bpm or > lasting more than 15 seconds. Type 1 deceleration nadir (lowest point) of deceleration coincides with the peak of uterine contraction Type 2 deceleration nadir of deceleration lags behind and persist even after the peak of uterine contraction Variable deceleration pattern nadir variable in depth and timing peak of contraction

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45. Principles of Fetal Monitoring 56

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47. Meconium Stained Liquor Sign of fetal compromise Can only be diagnose during labour , or only after the membrane have been ruptured May be due to Intestinal hurry Spontaneous dilatation of anal sphincters Manifestations of foetal hypoxia.

48. OTHERS MONITORING Mohd Hanafi Ramlee

49. Principles of Fetal Monitoring 61 Biochemical Screening Prenatal screening test: Fetal nuchal - measurement of fluid filled translucency space on post. surface of fetal neck. - increase measurement associated with fetuses with major chromosomal abnormalities and sex chromosomal abnormalities (e.g. Down syndrome). Maternal serum screening - neural tube defect and Down syndrome .

50. Principles of Fetal Monitoring 62 Fetal Nuchal Translucency

51. Principles of Fetal Monitoring 63 Maternal full blood indices/electrophoresis – detect thalasemia . Sickledex test – sickle cell disease. Maternal blood group/rhesus antibodies. Maternal serum virology – CMV/toxoplasmosis/ Rubella /parvovirus Serology for syphilis.

52. Principles of Fetal Monitoring 64 Maternal Serum Screening 15 – 20 weeks of gestation. maternal serum alpha-fetoprotein (AFP) screening for neural tube defects (NTDs) and Down syndrome . Increase level - fetal open NTDs. Decrease level - Down syndrome. Screening test on Down syndrome: maternal serum AFP. human beta-chorionic gonadotropin unconjugated oestriol . advanced age – risk.

53. Biophysical Profile Biophysical variable Normal (score 2) Abnormal (score 0) Fetal breathing movements > 1 episode for 30s in 30 min Absent < 30s in 30 min Gross body movements > 3 body/ limb movements in 30min < 3 body/ limb movements in 30min Fetal tone > 1 episode body/ limb extension followed by return to flexion, open-close cycle of fetal hand Slow, or absent extension-flexion of or body or limbs Reactive fetal heart rate >2 accelerations with fetal movements in 30min <2 accelerations, or 1+deceleration in 30min Qualities amniotic fluid >1 pool of fluid, at least 1cm x 1cm Either no measurable pool, or pool <1cm x 1cm

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