FETAL MEASURE

INTRODUCTION:-
Majority (80%) of fetal deaths occur in the antepartum period. The
important causes of deaths are-
i. Chronic fetal hypoxia (IUGR)
ii. Maternal complications e.g. diabetes, hypertension, infection
iii. Fetal congenital malformation and
iv. Unexplained causes
There is progressive decline in maternal deaths all over the world. Currently more interest
is focussed to evaluate the fetal health. The primary objective of antenatal fetal
assessment is to avoid fetal death. As such simultaneously with good maternal care during
pregnancy and labour, the fetal health in utero should be supervised with equal vigilance.

AIMS OF ANTENATAL FETAL MONITORING:-

 To ensure satisfactory growth and well being of the fetus throughout pregnancy.
 To screen out the high risk factors that affects the growth of the fetus.

INDICATIONS:-
Common indications of antenatal fetal monitoring-
 Pregnancy with obstetrics complications- IUGR, multiple pregnancy, Polyhydramnios
or oligohydramnios, Rhesus allomunisation.
 Pregnancy with medical complications- Diabetes mellitus, Hypertension, Epilepsy,
Renal or Cardiac disease, Infection (Tuberculosis), SLE.
 Others – Advance maternal age (>35 years), previous still birth or recurrent abortion,
previous birth of a baby with structural (anencephaly, spina bifida ) or chromosomal
(autosomal trisomy) abnormalities.
 Routine antenatal testing.

COMPONENT OF FETAL ASSESSMENT:-

There are 3 components:-

CLINICAL
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PARAMETERS
 BIOCHEMICA BIOPHYSICAL
L METHODS
METHODS

1. CLINICAL PARAMETERS:-
At every antenatal visit, the following clinical
parameters are taken into account for assessment of satisfactory progress of gestation.
i. Maternal weight gain,
ii. Blood pressure,
iii. Assessment of size of uterus and height of fundus.

i. MATERNAL WEIGHT GAIN:-

 During the second half of pregnancy, the average weight gain is 1 kg a fortnight.
 Excess weight gain: could be 1ST sign of pre-eclampsia.
 If weight gain less than normal stationary or falling: look for IUGR.

ii. BLOOD PRESSURE:-

 Initial recording of blood pressure prior to 12 weeks helps to differentiate pre-existing
chronic hypertension from pregnancy induced hypertension.
 Hypertension, pre-existing or pregnancy induced may impair fetal growth.

iii. ASSESSMENT OF SIZE OF UTERUS & HEIGHT OF FUNDUS:-

In early weeks, the size of the uterus is great value in confirming the calculated
duration of gestation. The height of the fundus should be documented at each visit.
 The top of the uterine fundus is measured from the superior border of of the
symphysis pubis (bladder should be empty) using a tape.
 After 24 weeks of pregnancy, distance measured in cm normally corresponds to the
period of gestation in weeks

2. BIOCHEMICAL TESTS/ METHODS:-

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 HUMAN ESTRIOL,
 ACETYL CHOLINE ESTRASE (ACHE),
 MATERNAL SERUM ALPHA FETOPROTIEN,
 TRIPLE TEST,
 AMNIOCENTHESIS,
 CARDOCENTHESIS,
 CHORIONIC VILLUS SAMPLING.

 HUMAN ESTRIOL:-
ESTROGEN-
An estrogen test measures the level of the most important estrogen hormones
in a blood or urine sample. It measures estradiol, estriol, and estrone.

PURPOSES:-
 Help find fetal birth defects
 Check for estrogen-producing tumours of the ovaries
 Monitor treatment with fertility medicines.

PROCEDURE:-

 Wrap an elastic band around upper arm to stop the flow of blood. This makes veins below
the band larger so it is easier to put a needle into the vein.
 Clean the needle site with alcohol.
 Put the needle into the vein. More than one needle stick may be need.
 Attach a tube to the needle to fill it with blood.
 Remove the band from your arm when enough blood is collected.
 Put a gauze pad or cotton ball over the needle site as the needle is removed.
 Put pressure on the site and then put on a bandage.
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RESULTS-
Estriol in pregnant women-
 1st trimester-Less than 38 nanograms/mL
 2nd trimester-38-140 ng/mL
 3rd trimester-31-460ng/Ml

 ACETYL CHOLINE ESTRASE (ACHE):-

This test measures the amount of an
enzyme called acetylcholine esterase in amniotic fluid. It is used during pregnancy to help
identify unborn babies who have neural tube defects, including anencephaly, spina bifida,
and heart defects.

INDICATIONS-
 Patients on valporic acid anti-seizure medication,
 Insulin dependent diabetic patients,
 Previous pregnancy with a NTD,
 Ultrasound indications of a NTD or open ventral wall defect.

PROCEDURE-

 A sample of this fluid is collected by a procedure called an amniocentesis.

RESULTS-
Normal range by method :
 Polyacrylamide gel electrophoresis: Negative
 AE-2 immunoassay: Negative
 Inhibition assay:5.17+_2.63 milliunits/mL

 MATERNAL SERUM ALPHA FETOPROTIEN:-

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 MSAFP is a screening test that examines the level of alpha-fetoprotein in the mother’s
blood during pregnancy.
 Normally, low levels of AFP can be found in the blood of a pregnant woman. No AFP (or
only very low level) is generally found in the blood of healthy men or healthy,
nonpregnant women.

PURPOSE-
 Check the developing baby (fetus) of a pregnant woman for brain or spinal problems
 Check the developing baby (fetus) of a pregnant woman for down syndrome.
 Find certain cancers, especially cancer of the testicles, ovaries, or liver
 Check how well treatment for cancer is working.
 Check for liver cancer (called hepatoma) in chronic hepatitis B.

PROCEDURE-
 The health professional drawing blood will:
 Wrap an elastic hand around your upper arm to stop the flow of blood. This makes the
veins below the band larger so it is easier to put a needle into the vein.
 Clean the needle site with alcohol.
 Put the needle into the vein. More than one needle stick may be needed.
 Attach a tube to the needle to fill it with blood.
 Remove the band from your arm when enough blood is collected.
 Put a gauze pad or cotton ball over the needle site as the needle is removed.
 Put pressure on the site and then a bandage.

RESULTS-
Alpha-fetoprotein in blood
 Men and nonpregnant women: 0-40 nanograms/Ml or micrograms/L
 Women 15-18 weeks pregnant: 10-150 nanograms/Ml
High values- In a pregnant woman, high alpha-fetoprotein values can mean:
 The age (gestational age) of the baby is wrong,
 The woman is pregnant with more than one baby, such as twins or triplets.
 The baby has a neural tube defect.

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 The baby’s intestines or other abdominal organs are outside the body (called an
abdominal wall defect or omphalocele). Surgery after birth will be needed to correct the
problem.
 The baby is not alive.
Low values- In a pregnant woman, a low level of alpha-fetoprotein can mean:
 The age (gestational age) of the baby is wrong.
 The baby may have Down syndrome.

 TRIPLE TEST:-
The triple screening measures the amounts of three substances in a
pregnant woman’s blood: alpha-fetoprotein (AFP), human chorionic gonadotrophin
(HCG), and estriol (Ue3). This is also called the maternal serum triple, the expanded AFP
test, the AFP plus test, or the multiple marker screening tests.
 Down syndrome

 Spina bifida

 Anencephaly

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INDICATIONS-
All pregnant women in the second trimester (between weeks 15 and 22)
are tested. Those in the following categories are at higher risk:
 Women over 35 years old
 Those taking insulin for treating diabetes
 Women having a family history of birth defects
 Use of certain medications
 Exposure to high radiation levels
 Having complications, viral infections, during pregnancy.

PROCEDURE-
 Wrap an elastic band around ypur upper arm. This makes the veins below the band larger
so it is easier to put a needle into the vein.
 Clean the needle site with alcohol.
 Put the needle into the vein.
 Attach a tube the needle to fill it with blood.
 Remove the band from your arm when enough blood is collected.
 Put a gauze pad or cotton ball over the needle site as the needle is removed.
 Put pressure on the site and then put on a bandage.

RESULTS-
 A “positive” result means that there is a higher-than-average chance, baby has at birth
defect. If the result is “negative”, or normal, it means that baby probably doesn’t have a
birth defect.

 AMNIOCENTESIS:-
Amniocentesis is a prenatal test in which a small amount of amniotic fluid is removed from
the sac surrounding the foetus for testing. The sample of amniotic fluid is less than one
ounce.

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 INDICATIONS-
Genetic diagnosis:
 Down syndrome (trisomy 21)

 Patau syndrome (trisomy 13)

 Edward’s syndrome (trisomy 18)

 Rare, inherited metabolic disorder

 Neural tube defects

 Lung maturity
Other- Amniocentesis can also be used to detect problems such as:
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 Infection, in which amniocentesis can detect a decreased glucose level, a Gram stain
showing bacteria or an abnormal differential count if white blood cells.
 Rh incompatibility
 Decompression of poly hydramnios

PROCEDURE-
 The woman’s abdomen is cleaned with antiseptic.
 A fine sterile needle is guided through the woman’s abdominal wall and the wall of the
uterus (womb) into the amniotic fluid.
 The path of the needle is watched by ultrasound.
 As the procedure is rapid, a local anaesthetic is usually not necessary.
 Most women say that the procedure is no more painful than any type of injection. Some
women feel cramping when the needle enters the uterus or pressure as the fluid is being
withdrawn.
 Once the needle is seen to be in the right place, a small amount (about 20ml) of amniotic
fluid is taken out and the needle is withdrawn.
 The sample of amniotic fluid is sent to the laboratory for testing.
 The amount of amniotic fluid in the uterus returns to normal within a few hours.
 Occasionally the doctor is unable to obtain enough amniotic fluid on the first attempt. If
this happens, another sample may need to be taken.

COMPLICATIONS-
 Amniocentesis is performed between the 15th and 20th week of pregnancy, performing
this test earlier may result in fetal injury.
 Complications of amniocentesis include preterm labor and delivery.
 Chance of infection and miscarriage.
 Ethical problem arise when parents decide for an abortion following the test results when
there is a baby girl in the womb of mother.
 It is expensive process.

 CORDOCENTHESIS:-
Cordocenthesis, also sometimes called Percutaneous
Umbilical Cord Blood Sampling (PUBS), is a diagnostic test which examines blood from
the foetus to detect foetal abnormalities.

INDICATIONS-
 High risk of chromosomal disorder (based on biochemical screening):
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 Identification of anomalies during foetal ultrasound, which may be associated with
chromosomal diseases (e.g. Short femur, hypoplasia of the nasal bone and other).
 The presence of the parents of hereditary diseases, if they already have children with
congenital developmental disorders,
 Suspension of Rhesus-conflict, intrauterine infection,
 Suspicion of haemophilia.

CONTRAINDICATIONS-
Cordocenthesis is contraindicated in infectious processes,
with cervical incompetence (cervical insolvency), with large myoma nodes (in the projection
of the puncture) and bleeding disorders in pregnant women. Cordocenthesis is also
impossible to carry out the threat of termination of pregnancy.

PROCEDURE-

 An advanced imaging ultrasound determines the location where the umbilical cord insert
into the placenta. The ultrasound guides a thin needle through the abdomen and uterine
walls to the umbilical cord. The needle is inserted into the umbilical cord to retrieve a
small sample of foetal blood.
 The sample is sent to the laboratory for analysis, and results are usually available within
72 hours.

RISK AND SIDE EFFECTS TO THE MOTHER OR BABY-

 Miscarriage
 Other potential side effects includes: Blood loss from the puncture site, Infection,
 Drop in foetal heart rate
 Premature rupture of membranes
 Contact your healthcare provider if these symptoms remain or get worse.- fever, chills,
and leaking of amniotic fluid.

COMPLICATIONS-
 Bleeding from the puncture area

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 Violation of the functional state of the foetus as choriamnionitis
 Alloimmune cytopenias (the baby).

 CHORIONIC VILLUS SAMPLING:-

Chorionic villus sampling (CVS), sometimes called “chorionic villous sampling” (as
“villous” is the adjectival form of the word “villus”), is a form of prenatal diagnosis to
determine chromosomal or genetic disorders in the foetus.

INDICATIONS-
Possible reasons for having a CVS can include:
 Abnormal first trimester screen results
 Increased nuchal translucency or other abnormal ultrasound findings
 Family history of a chromosomal abnormality or other genetic disorder
 Parents are known carriers for a genetic disorder
 Advanced maternal age (above 35 years). AMA is associated with increase risk of
Down’s syndrome and at age 35, risk is 1:400. Screening tests are usually carried out first
before deciding if CVS should be done.

PROCEDURE-
These are two ways samples are collected:
 TRANSCERVICAL-

An ultrasound guides a thin catheter through the cervix to your placenta. The chorionic villi
cells are gently suctioned into the catheter. This is the most common method.
 TRANABDOMINAL-

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An ultrasound guides a long thin needle through the abdomen to your placenta. The needle
draws a sample of tissue and then is removed. This procedure is similar to that amniocentesis.

RISK AND SIDE EFFECTS OF THE MOTHER OR BABY-

 Miscarriage
 CVS is not recommended for women who:- Have an active infection (STD)
 Are carrying twins baby
 Have experienced vaginal bleeding during pregnancy
 Transcervical CVS is not recommended for women who: Have uterine fibroids
 Have a tilled uterus which impedes the catheter
Following the procedure, the mother may experience one or more of the following side
effects:
 Infection
 Spotting
 Cramping and pain at puncture point

RESULTS-
Normal: - No abnormalities are found in the genetic material of the chorionic villus cells.
Abnormal: - Abnormalities are found in the genetic material of the chorionic villi.

CONCLUSION:-
Biometric fetal parameter measurements may be reproducible by
different operators in the clinical setting with similar results. Fetal heads circumference and
femur head circumference, abdominal circumference and femur length were highly
reproducible. Large organized studies are needed to ensure accurate fetal measurements due
to the important clinical implications of inaccurate measurements.

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 BIBLIOGRAPHY
 Jacob. A. (2019). A Comprehensive Text Book Of Midwifery & Gynaecology Nursing,
(5th ed). Jaypee Brothers medical publisher (P)Ltd. New Delhi. Page no-98
 Boback M Irene & Jenson Margaret. Maternity & Gynaecologic care, mosby company
(5th ed).page no-864-868
 Dutta D.C. (2004). Text book Of Obstetrics, (6th ed).New Central Book Agency. India.
Page no-104-107
 Myles (2003).. Text Book For Midwives. (14th ed). Philadelphia. Churchill livingstone
publishers. Page no-621-623
 www.Google.com
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