7 non invasive & invasive

1. 1. NEWER MODALITIES OF PREGNANCY- INVASIVE AND NON INVASIVE

KHUSHBU PATEL GCS SCHOOL/COLLEGE OF NURSING
2. 2. INTRODUCTION • Many changes occur in woman’s body during pregnancy. These
changes although most apparent in the reproductive organs, involve other body systems
as well. • Weeks may pass before the family realizes she has become pregnant or she
may learn upon a visit to a doctor for other reasons • Confirmation her pregnancy is most
important for the health & welfare of herself & the baby. In this lesson, we will cover the
tests used to determine pregnancy
3. 3. RISK APPROACH SCREENING • Blood testing • Excessive weight gain of the mother
due to fluid retention. Falling weight also poses risk as there can be intrauterine growth
retardation. • Pre-existing hypertension or PIH • Excess amount or decreased amount of
amniotic fluid is another risk factor. • Other approaches, which should be followed for
high-risk cases, are: non-invasive & invasive methods are used
4. 4. • Non-invasive methods: • Examination of the woman’s uterus from outside the baby. •
Listening to the fetal heart sound • External fetal monitoring • It includes:
Ultrasonography, • Cardiotocography, • Non- stress test, • Contraction stress test, •
amniotic fluid index
5. 5. • Invasive methods: • Chorionic villus sampling • Amniocentesis • Fetoscopy • MSAFP:
maternal serum alpha feto protein. • Others includes Cordocenthesis, Amnioscopy.
6. 6. OBJECTIVE OF INVASIVE & NONINVASIVE DIAGNOSIS • To reduce maternal and
fetal mortality rate. • To check fetal growth and development. • To enable timely medical
or surgical treatment of a condition before or after birth, • To give the parents the chance
to abort a fetus with the diagnosed condition, • To give parents the chance to "prepare"
psychologically, socially, financially, and medically for a baby with a health problem or
disability, or for the likelihood of a stillbirth
7. 7. Common indicators of invasive & noninvasive diagnosis:-
8. 8. • 1) ULTRASONOGRAPHY • 2) CARDIOTOCOGRAPHY • 3) NON STRESS TEST •
4) CONTRACTION STRESS TEST • 5) AMNIOTIC FLUID INDEX (AFI) NON-INVASIVE
METHODS OF DIAGNOSIS
9. 9. ULTRASONOGRAPHY (USG) • An ultrasonography is a diagnostic technique, which
uses high-frequency sound waves to create an image of the internal organs. • A
screening ultrasound is sometimes done during the course of a pregnancy to check
normal fetal growth and verify the due date. • It is a safe , non invasive, accurate and cost
effective investigation • Hard tissues such as bone appear white on the image and soft
tissues appear grey.
10. 10. Indications: • In the first trimester: • To establish the dates of a pregnancy • To
determine the number of fetuses and identify placental structures • To diagnose an
ectopic pregnancy or miscarriage • To examine the uterus and other pelvic anatomy • In
some cases to detect fetal abnormalities as anencephaly
11. 11. • Mid-trimester: (sometimes called the 18 to 20 week scan)to confirm pregnancy
dates or gestational age • To determine the number of fetuses and examine the placental
structures • To assist in prenatal tests such as an amniocentesis, Cordocenthesis . • To
examine the fetal anatomy for presence of abnormalities • To check the amount of
amniotic fluid by measuring AFI. • To examine blood flow patterns • To check on the
location of placenta; to see if its covering cervix • To observe fetal behavior and activity
12. 12. • Third trimester: • To monitor fetal growth, to check IUGR • Detailed anatomical
survey. • To check the amount of amniotic fluid • to determine the position of a fetus • To
assess the placenta
13. 13. types of ultrasounds performed during pregnancy Abdominal ultrasound Transvaginal
ultrasound
14. 14. Abdominal ultrasound • In an abdominal ultrasound, gel is applied to the abdomen
and the ultrasound transducer glides over the gel on the abdomen to create the image
15. 15. TRANSABDOMINAL USG
16. 16. TRANSVAGINAL ULTRASOUND • a smaller ultrasound transducer is inserted into
the vagina and rests against the back of the vagina to create an image. • A transvaginal
ultrasound produces a sharper image and is often used in early pregnancy.
17. 17. TRANSVAGINAL USG
18. 18. • Indication of transvaginal ultrasound:- • Early month of pregnancy • In this high
frequency of sound waves used so greater resolution is possible • Typical gynaecological
indication includes uterine size, evaluation of endometrium, myometrium, cervix •
Contraindication:- • Allergy to latex. • Vaginal infection
19. 19. Nursing responsibility before procedure • Explain the purpose of procedure and how it
will be done. • Advise for drink lots of water so that full bladder to capture clearer images
• Provide privacy. • Provide supine position . (dorsal position). • The abdominal wall is
prepared and draped. • Check USG
20. 20. Procedure : • TRANS ABDOMINAL USG:- • Explain the procedure to the patient. •
Provide privacy • Provide supine position to the patient. • Apply gel
21. 21. Transvaginal USG • A probe is placed into the vagina instead of over the abdomen. •
Provide dorsal lithotomy position with empty bladder. • Vaginal probe should be
lubricated with gel and the probe should be inserted in to an appropriate covering sheeth
such as condom • The sheath covered probe is gently advanced up the vaginal canal • If
ultrasound is done before the week 11, it would be transvaginal
22. 22. Safety of USG • Ultrasounds bring no long term or short-term harm to both mother
and baby. • In fact, it is a useful scanning tool. Because the waves are of very low
intensity, there is no danger in repeating the scans, if your condition merits it. • However
if pregnancy is normal, then 2 routine scans as part of antenatal care. • More scans are
only necessary if any medical condition
23. 23. Advantage of USG • Complex structure can be viewed in a single image. • Stored
data can be reviewed at any plane later on without needing the patient, this helps to get
second opinion if required. • Prenatal diagnosis of certain anomalies is improved. • Photo
of 3- Dimensional image improves antenatal parental bonding and important teaching
tool.
24. 24. CARDIOTCOGRAPHY • Cremer first demonstrates this method in 1904. In this test,
Fetal Heart Rate and uterine contraction are graphically recorded. It is generally
performed in third trimester. • The machine used to perform the monitoring FHR called a
cardiotocograph or electronic fetal monitor or external fetal monitor
25. 25. CARDIOTOCOGRAPH
26. 26. CARDIOTOCOGRAPH
27. 27. Procedure
28. 28. • INTERPRETATION • A typical CTG output for a woman not in labour. A: Fetal
heartbeat; B: Indicator showing movements felt by you (caused by pressing a button); C:
Fetal movement; D: Uterine contractions
29. 29. Advantages:- • Help to detect hypoxia in early stage. • Reduce fetal death • It is
important record for medico-legal purpose Drawback • Instrument is expensive and
trained person are required to interpret. • Mother has to confined in bed • Due to false
prediction caesarean section rate may be high
30. 30. Non-stress Test ( NST) • Non-stress test is a simple, painless procedure in which a
baby's heartbeat is continuously monitored for 20 minutes or more along with recording
fetal movement. • The logic behind the test is, that like adults, a baby's heartbeat should
accelerate when it is active i.e. moving and kicking. • Principle : there is acceleration of
fetal heart rate with each fetal movement
31. 31. Performing time:- • The Non-stress test can be done whenever the need arises so
there is no specific time for it. around 30 weeks
32. 32. Indications of NST • Women with preexisting medical conditions such as diabetes. •
Women with pregnancy-induced medical conditions such as hypertension • Baby is less
active than normal • Baby is small for its age • Amniotic fluid is either too much or too
little • Women who have previously lost their babies in the second half of their
pregnancies • Women with pregnancies continuing after week 40 to basically check on
the well- being of baby
33. 33. Nursing responsibility • Explain procedure before performing test. • Informed consent
should be given prior to testing, and a woman has the right to refuse this test if she
chooses • Provide lateral position or semi fowler or sitting position to the women. • the
recording is obtained with the patient lie down on left side, or lateral recumbent position. (
to avoid supine hypotension)
34. 34. Procedure
35. 35. Contd… • Two electronic devices will be strapped to mother abdominal. • The
transducer ultrasound will monitor baby's heartbeat. • The other device will record any
uterine contractions felt by the mother. • While fetal movement is recorded by mother by
pressing a button which makes the mark on the strip. • If there are no movements, the
fetus is stimulated manually or may be with a buzzer • The test takes about 20 minutes to
an hour
36. 36. Interpretation • Reactive test (normal NST) :- NST is called reactive if there are at
least 2 fetal movements in 20 minutes with acceleration of FHR by 15 beats/min for
atleast 15 seconds • Non-reactive: absence of any fetal reactivity. It is associated with
poor fetal and neontatal outcome, but there is high incidence of false positive results
also. This may be due to fetal sleep, sedative or narcotic drugs, congenital anomalies
and premature fetus
37. 37. Procedure :-
38. 38. • Advantages: - • It is a non-invasive test. • The test is simple, inexpensive and takes
less time. • There are no contradictions or complications • No special expertise required •
Provide immediate answer. • It can be repeated as many times as required without any
risk.
39. 39. CONTRACTION STRESS TEST • Tests will be carried out to analyze the baby's well
being • CST is based on the observation that during contractions, blood flow to the
placenta lessens temporarily. An evaluation is done on how the fetus handles this stress.
• Normally fetal heart rate is not affected by contractions
40. 40. • In actual labor after contraction begins, if the fetal heartbeat slows down, it indicates
that the fetal is not able to tolerate the decreased blood flow resulting from the
contraction. • These decreases are called late decelerations. • If the placenta is not
working to capacity or the baby has some problem, Contraction can decrease the oxygen
flow and cause the heart rate to drop.
41. 41. • Performing time: after 30 weeks gestation • Position:- • Semi recumbent position •
Lateral position
42. 42. Indication: • It is usually conducted if the pregnant woman has had problematic
pregnancies in the past or has medical problems in her current pregnancy. • CST is
usually performed if Non-stress test showed no change in fetal heart rate when the fetus
moved. • To check baby will remain healthy during the reduced oxygen levels that
normally occur during contraction
43. 43. Procedure Two fetal monitors will be strapped to the woman's abdomen to record
fetal heart rate. • One monitor will pick up uterine contractions and the other picks up fetal
heart beat. . Both will readings will record on graph paper. • Stimulate contraction by
either nipple stimulation or oxytocin. • Assess the maternal B.P every 10 to 15 min during
the test.
44. 44. •The heartbeat will form a line at the top and the maternal contractions will form
wavelike lines at the bottom. Both lines will be matched to determine the significance of
any decelerations
45. 45. Result/ Interpretation • Negative- no late decelerations are present in the presence of
adequate contractions, the placenta is functioning properly and the fetus is doing well. It
is the desired result • Positive: late decelerations are present in the presence of adequate
contractions. Delivery of baby follows a positive result either by induction of labour or
LSCS
46. 46. Amniotic fluid index • Amniotic fluid index (AFI) is a rough estimate of the amount of
amniotic fluid and is an index for the fetal well-being. • AFI is the score (expressed in cm)
given to the amount of amniotic fluid seen on pregnant uterus and calculated by a
ultrasonograph ( ultrasound).
47. 47. • To determine the AFI, doctors may use a four-quadrant technique , when the
deepest, unobstructed, vertical length of each pocket of fluid is measured in each
quadrant and then added up to the others , or the so called "Single Deepest Pocket"
technique
48. 48. INVASIVE METHODS • MATERNAL ALPHA-FETOPROTEIN • AMNIOCENTESIS •
CHORIONIC VILLUS SAMPLING (CVS) • CORDOCENTHESIS OR PERCUTANEOUS
UMBLICAL CORD BLOOD SAMPLING (PUBS) • FETOSCOPY • AMNIOSCOPY
49. 49. Maternal alpha-fetoprotein screening (MAFP) • A blood test that measures the level
of alpha- fetoprotein in the mothers' blood during pregnancy. • AFP is a fetal protein
normally produced by the fetal liver and is present in the fluid surrounding the fetus
(amniotic fluid), and crosses the placenta into the mother's blood. • The AFP blood test is
also called MSAFP (maternal serum AFP
50. 50. Abnormal levels of AFP may signal the following MSAFP level high indicates:- Open
neural tube defects (ONTD) such as spina bifida • Other chromosomal abnormalities lead
to IUFD • Defects in the abdominal wall of the fetus • Twins more than one fetus is
making the protein • A miscalculated due date • Renal anomalies. MSAFP level low
indicates • Down’s syndrome • Gestational trophoblastic disease
51. 51. INDICATION • All pregnant women are usually offered the AFP test. But, the doctor
may recommend the test, especially if : • Mother is 35 or older • Have a family history of
birth defects • Have diabetes • Have taken certain drugs or medication during pregnancy
52. 52. • Time of performing test:- 15-18 weeks • PROCEDURE:
53. 53. Amniocentesis:- • It is a medical procedure used in prenatal diagnosis of
chromosomal abnormalities and fetal infections. • In which a small amount of amniotic
fluid, which contains fetal tissues, is extracted from the amniotic sac surrounding a
developing fetus , and the fetal DNA is examined for genetic abnormalities.
54. 54. • Definition:-it is deliberate puncture of the fluid sac per abdomen. • Indication :-
DIAGNOSTIC THERAPUETIC EARLY LATER
55. 55. • Time of performing:- performed between the 15th-20th weeks of pregnancy. Mostly
during the 18th week.
56. 56. Nursing responsibility before procedure • Before procedure, take written consent. •
Explain the purpose of procedure • Emptying the bladder AND Provide privacy. • Provide
supine position with elevated head • The abdominal wall is prepared aseptically and
draped. • Check the vital sign and FHR to obtain base line data. • Check USG. •
Prophylactic administration of 100 mg of anti –D immunoglobulin in Rh negative mother. •
The proposed site of puncture is unfiltered with 2 ml of 1% lignocainE
57. 57. Procedure
58. 58. • Nursing responsibility after procedure: • Fetus should be monitored for short period
after procedure, check FHR every 30 minutes. • Tell patient, to report physician if uterine
cramping, vaginal bleeding or leakage of fluid or fever. • Strenuous activities should be
avoided for 24 hours following an amniocentesis
59. 59. Contraindication:- • Acute skin infections near the site of needle placement. •
Maternal fever • Allergies to material used like skin preparation materials, local
anesthesia. • May be difficulty in-patient with multiple pregnancies
60. 60. COMPLICATION Maternal complication • Infection • Alloimmunisation of the mother •
Preterm labor and delivery • Hemorrhage Fetal complication • Miscarriage • Respiratory
distress, • Postural deformities, • Fetal trauma. • Oligohydramnions due to leakage of
Amniotic fluid
61. 61. Chorionic villus sampling CVS • Chorionic villous sampling a form of prenatal
diagnosis to determine chromosomal or genetic disorders in the fetus . • It entails getting
a sample of the chorionic villus (placental tissue) and testing it. • It can be performed in a
transvaginally or transabdominal manner
62. 62. Chorionic villus sampling CVS
63. 63. • Performing time: before 15 weeks, usually performed between the 10th and 12th
weeks of pregnancy. • Indications:- • Abnormal first trimester screen results • Increased
AFP or other abnormal ultrasound findings • Family history of a chromosomal abnormality
or other genetic disorder • Parents are known carriers for a genetic disorder • maternal
age above 35
64. 64. Procedure • TRANSVAGINALLY:
65. 65. TRANSABDOMINALLY
66. 66. • Contraindication :- • Active vaginal bleeding • Infection • Multiple gestation • HIV
infection
67. 67. • Nursing responsibility after procedure:- • Fetus should be monitored for short period
after procedure, check FHR every 30 minutes. • Tell patient, to report physician if uterine
cramping, vaginal bleeding or leakage of fluid or fever. • Strenuous activities should be
avoided for 24 hours following a CVS. • Anti –D immunoglobulin 50 ug IM should be
administered following the procedures to the Rh negative women’s
68. 68. • Complications :- • Miscarriage in CVS in about 0.5 - 1%. • Infection and amniotic
fluid leakage. The resulting amniotic fluid leak can develop into a condition known as
oligohydramnions • Mild risk of Limb Reduction Defects associated with CVS, especially
if the procedure is carried out in earlier terms (before 12th week of pregnancy). • Fetal
loss. • Infection • Vaginal bleeding
69. 69. Cordocenthesis OR Percutaneous umbilical cord blood sampling (PUBS) • It is a
diagnostic genetic test that examines blood from the fetal umbilical cord to detect fetal
abnormalities. • PUBS provides a means of rapid chromosome analysis and is useful
when information cannot be obtained through amniocentesis, CVS, or ultrasound • Time
of performance:-18 weeks of gestation
70. 70. Procedure • PUBS is similar to amniocentesis, but instead of sampling the amniotic
fluid which surrounds the fetus, PUBS examines fetal blood
71. 71. • Before the start of the procedure, a local anesthetic is given to the mother. • After
the local is in effect, a 25 gauze spinal needle 13 cm in length is usually inserted through
the mother's abdominal wall, • An advanced imaging ultrasound determines the location
for needle insertion, and the needle is guided through the mother's abdomen and uterine
wall into the fetal vein of the umbilical cord, approximately 1-2 cm from the placenta. •
The sample can then be sent for chromosomal analysis.
72. 72. COMPLICATIONS • Miscarriage is the primary risk associated with PUBS • Blood
loss at the puncture site, • Infection, and • Premature rupture of membranes. • During the
procedure, the mother may feel discomfort similar to a menstrual cramp. • Cord
hematoma formation • Preterm labor
73. 73. FETOSCOPY • A fibreoptic instrument that can be passed through the abdomen of a
pregnant woman to enable examination of the fetus and withdrawal of blood for sampling
in prenatal diagnosis. • DEFINITION • Examination of the pregnant uterus by means of a
fiber-optic tube. • Time of performing:-18th week of pregnancy
74. 74. • Complication :- • Miscarriage, as high as 12%. • Excessive bleeding, infection, or
excessive leakage of the amniotic fluid. • Preterm rupture of the membranes which may
require early delivery of your baby . • Mixing your blood with babys blood
75. 75. AMNIOSCOPY • Definition • Direct observation of the foetus and the colour and
amount of the amniotic fluid by means of a specially designed endoscope inserted
through the uterine cervix. • Contraindicated:- • Cervix is in insufficiently dilated •
Complication:- • Sepsis • Rupture of membrane