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antepartum assessment

antepartum assessment. Fetal movements Fetal breathing movements Contraction stress test Non-stress test Biophysical profile Amnionic fluid volume Umbilical Artery Doppler Velocimetry Current recommendations Significance of fetal testing. contents.

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antepartum assessment

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  1. antepartum assessment

  2. Fetal movements Fetal breathing movements Contraction stress test Non-stress test Biophysical profile Amnionic fluid volume Umbilical Artery Doppler Velocimetry Current recommendations Significance of fetal testing contents

  3. - In the 1st William obstetric edition 1903: FHR > 160 b/m or < 100 b/m is dangerous - Now the fetus is considered as a 2nd patient and exposed to serious morbidity and mortality > his mother - Fetal testing is now extended to the embryonic life: e.g. Embryonic HR may predict pregnancy outcome introduction

  4. Our goal is to prevent fetal death Fetal death within 7 days of a normal test is very rare In most tests: +ve predictive value (true +ve) = 99.8% --ve predictive value of abnormal tests (true –ve) = 10 – 40%

  5. Fetal movements

  6. - FMs starts at 7th week - At 8th week  FMs are never absent > 13 minutes - At 20 – 30 weeks  organization of FMs ( rest - activity cycles) - In the 3rd trimester until 36 weeks  maturation of FMs - > 36 weeks  behavioral states

  7. FHRFMs 1F quite sleep vvvvvv no 2F active sleep VVVVV I 3F VVVVV no 4F awake state VVVVV IIIIII + FHR accelerations The presence of F3 is debate Continuous eye movements are present in: 2F, 3F, 4F Behavioral states

  8. At 38 weeks 75% of the time 1F&2F Study: Urinary bladder ↑ in 1F and ↓ in 2F Sleep – awake cycles: Sleep  20 - 75 minutes Mean = 23 minutes Maternal perception of FMs is described as: weak - strong - rolling

  9. FMs is α to AFV: As GA ↑ > 20 weeks  weak FMs ↓ vigorous FMs ↑ > 32 weeks strong FMs ↓ due to: • ↓ AFV • ↓ space Normal FMs: = 4 – 10 FMs / 12 hours

  10. In 1973  ↓ FM precede fetal death Methods of measuring FMs: • Tocodynamometer • U/S • Maternal perception Study: Maternal perception = 80% of FMs by U/S Study: - > 36 weeks, maternal perception = 16% - Longer FMs > 20 seconds are better felt

  11. Optimal number and duration of FMs: Not defined Study: Normal FMs = 10 FMs/2 hours Study: FM/1 hour is good if ≥ previous count Patient complaint of ↓ FMs in the 3rd T: Not uncommon = 7%  same pregnancy outcome  Evaluate & reassure

  12. NST is indicated if: • Abnormal fetal growth by U/S • Abnormal Doppler Study: Mean duration to record 10 FMs = 2.7 hours of counting/day Study: Asking mothers about FMs each visit = counting FMs

  13. Ii - breathing movements

  14. In 1972  inward and outward flows of tracheal fluid in sheep = BMs BMs differ from FMs: • Paradoxical = inspiration collapse expiration distend • Not continuous May be coughing to expel AF debris Essential for fetal development

  15. Types of BMs: • Gasps/sighs = 1 - 4/minute • Irregular bursts = up to 240c/m As GA ↑  BMs rate ↓ & volume ↑ At 33 – 36 weeks = lung maturation 30 - 40 weeks  diurnal variation: • ↑ after meals • ↓ at night

  16. If BMs are not seen extend U/S evaluation for up to 2 hours before diagnosis of absent BMs Factors affecting BMs: Hypoxia Sound Hypoglycemia Cigarette Labor FHR Impending PTL GA Amniocentesis

  17. BMs as a marker of fetal wellbeing: Unfulfilled because multiple factors it affect it, but it is included in BPP with Other indices

  18. Iv - contraction stress test

  19. Basis: Uterine contractions  ↑ amnionic fluid P  collapse of uterine vessels  isolation of intervillous space  transient ↓ O2 exchange If uteroplacental pathology is present  late decelerations

  20. CST is present since 1972 Late decelerations: Start at/or beyond the acme of uterine contraction Disadvantages: Require 1 ½ hours

  21. Method: Oxytocin 0.5 mIU/minute by infusion pump doubled /20 minutes  3 contractions in 10 minutes duration of each ≥ 40 seconds Nipple stimulation: 1 nipple is rubbed through her clothes for 2 minutes or until contractions start, restart After 5 minutes  3 contractions in 10 min Advantages: ↓ time and cost May  hyperstimulation with mild FD

  22. Negative: No LD or significant VD Positive: LD + 50% of contractions even if contractions are < 10/m Equivocal-suspicious: • Intermittent LD • Significant VD Equivocal-hyperactive: • LD + > 3 contractions/10m • Contraction > 90 seconds Unsatisfactory: • < 3 contractions /10m • Uninterruptable tracing Criteria for interpretation of cst

  23. Vi – nonstress test

  24. 1975 Basis: FMs  FHR accelerations = good sign Equipments: • Doppler • Maternal perception of FMs Differ from CST and much easier Used to discriminate false +ve CST Used in BPP

  25. Physiology: Beat to beat variability > 5 b/m + FHR accelerations = good autonomic function Most common causes of no accelerations: • Fetal sleep • Drugs As GA ↑  ↑ FMs + ↑ FHR accelerations 25 – 28 weeks accelerations are 70% 15 b/m for 15 seconds 90% 10 b/m for 10 seconds < 32 weeks use 10 b/m for 10 seconds

  26. Normal NST: Vary in number, amplitude & duration of acceleration = ≥ 2 accelerations that peak at ≥ 15 b/m for ≥ 15 seconds in 20 minutes ± FM 1 acceleration is enough by some If no accelerations  extend examination to 40-75-80-120 minutes before diagnosis of nonreactive NST

  27. No accelerations = not bad fetus False +ve NST ≥ 90% Disadvantages of NST: • ↑cost • Irreducibility Computerized analysis: • ↓ cost • Reliable • objective

  28. Abnormal NST: - Silent oscillatory pattern = ominous = beat - to - beat variability < 5 b/m + no accelerations - Terminal cardiogram: Both + LD = uteroplacental insufficiency

  29. Abnormal NST is associated with: FGR 75% Oligohydramnios 80% Acidosis 40% Meconium 30% Placental infarction 93% Study: Nonreactive NST for ≥ 90 min is associated with ↑ perinatal pathology in 93%

  30. Interval between tests: 1/week 2/week, 1/day, > 1/day in: • Postterm • Type 1 DM • FGR • PIH

  31. Decelerations: Normally present in ½ to 2/3 of fetuses Variable decelerations: Not ominous if nonrepetitive and brief < 30 seconds Repetitive VD ≥ 3 /20 minutes even if mild are associated with ↑ CS for FD Decelerations ≥ 1 min  bad prognosis

  32. Study: - Addition of NST to AFV  75% CS for FD in cases of ↑ VD + ↓ AFV - FD in labor + normal AFV is increased in patients with VD False - normal NSTs: = fetal death within 7 days of a normal NST

  33. Mean interval between testing and death: = 4 days Range: = 1 - 7 days Most common indicationof NST: = postterm Most common autopsy findings: • Meconium • Abnormal umbilical cord

  34. = Acute asphyxial insult = NST is inadequate to preclude such an acute asphyxial events Other causes: • Fetomaternal Hg • Infection • Abruptoplacenta • Congenital anomalies • Abnormal cord insertion

  35. Acoustic Stimulation Tests: Artificial larynx  acoustic stimulation to ↑ acceleration Method: External sound for 1 – 2 seconds Repeat 1 – 3 times for up to 3 seconds Still under evaluation

  36. Vii – biophysical profile

  37. Manning & colleagues 1980 5 variables to ↓ false +ve ↓ false –ve results Equipments: • Doppler • Real time U/S Duration of testing: 1/2 – 1 hour

  38. 2 0 NST ≥ 2 accelerations < 2 (≥15 b/m for ≥15 sec in 40 minutes) FBMs ≥ 1 ≥ 30 sec in 30 m < 30 sec FMs ≥ 3 in 30m < 3 F Tone ≥ 1 -- AFV > 2 cm ≤ 2 cm ( largest single vertical pocket)

  39. Fetal tone = flexion and extension of one limb or opening or closing hand NST is not required if the 4 variables are normal AFI if the largest vertical pocket is ≤ 2 cm  should be evaluated BPP = 6 is equivocal and poor predictor of abnormal outcome BPP = < 6 is progressively more accurate predictor of abnormal outcome

  40. Study: BPP followed by cordocentesis for pH: - 20% of fetuses are FGR - 80% of fetuses have alloimmune hemolytic anemia BPP = 0 is associated with acidemia BPP = 8 - 10 is associated with normal pH

  41. Study: BPP+cordiocentasis in DMno benefit Study: BPP+cordiocentasis in GRno benefit The morbidity and mortality in GR depend on GA & wt not BPP results Modified BPP( abbreviated BPP 1989): = vibroacoustic NST + AFV X 2/week Duration of testing = 10 minutes

  42. If AFV is < 5 do complete BPP or CST CST ↑CS for false abnormal results Acceptable by ACOG False –ve rate = 0.8 : 1000 False +ve rate = 1.5 : 1000 Study: Excellent method with no unexpected FD

  43. BPP = 10:  Repeat 1/w 2/w in DM & postterm BPP = 8 -10 + normal AFV:  Repeat BPP = 8 -10 + ↓ AFV: Chronic fetal asphyxia suspected  Deliver Modified BPP management

  44. BPP = 6: Possible fetal asphyxia If > 36 weeks + normal AFV + favorable cervix  deliver If < 36 weeks + normal AFV  repeat: if ≤ 6  deliver if > 6  repeat If + ↓ AFV  deliver

  45. BPP = 4: Probable fetal asphyxia  repeat same day if ≤ 6  deliver BPP = 0 - 2: Almost certain fetal asphyxia  deliver

  46. Viii – amnionic fluid volume

  47. Basis: Uteroplacental insufficiency  ↓ fetal renal blood flow  ↓ urine production  ↓ AFV Methods: • AVI • Largest vertical pocket • 2 x 2 cm pocket

  48. Study: AFI < 5 cm  ↑ CS for FD ↑ low 5 minutes Apgar score ↑ perinatal morbidity & mortality Study: 20% of fetuses have AFI < 5 cm AFI = poor diagnostic test Study: Same results in severe preeclampsia

  49. Study: Nonintervention to permit spontaneous VD in fetuses with AFI < 5  same pregnancy outcome as induction of labor

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