ESTABLISHING AGE OF GESTATIoy 1. __ IMPORTANCE OF AN ACCURATE GESTATIONAL AGE Proper diagnosis and management of preterm labor and post-term pregnancy Timing of repeat caesarean section requires accurate assessment of dates Essential in the evaluation of fetal growth and the detection of intrauterine growth rest Important in accurate interpretation of antenatal biophysical testing Fiction Dating a pregnancy is imperative for scheduling invasive diagnostic tests such as chorionic villye sampling or amniocentesis, as appropriate timing can influence the safety ofthe procedure . © Important in the interpretation of biochemical serum screening test results Il. METHODS OF GESTATIONAL AGE ASSESSMENT A. Clinical Predictions of Gestational Age i. Last Menstrual Period (LMP) ii. Problem with using LMP: 20 to 40% of women cannot remember the LMP with certainty, some of the reasons include: Oligomenorthea Metrorrhagia Bleeding in the first trimester of pregnancy Pregnancy following the use of oral contraceptives or intrauterine devices Becoming pregnant in the postpartum period iii, Quickening iv. Uterine size by bimanual examination in the first trimester \._ Initial detection of fetal heart tones by Doppler(10-12 weeks) or auscultation (19-21weeks), and uterine fundal height measurement B. Ultrasonographic Parameters The advent of ultrasound has allowed a more direct means of assessing fetal stuctures and development TABLE-59.6. Fetal Structures assessed based on Gestational Age ET ac eines) Gestational sac frst identifiable structure 50 {no yolk sc, embryo, heart beat) ‘Gestational sacand yolk sac 55 (no embryo, no heartbeat) Gestational sacand yelk sac 60 (living embryo too small to measure, with cardiac activity) Embryoetus >Smm in length ‘Age based on the CRL | Latest iaGnostics & THERAPEUTICSMl. ULTRASONOGRAPHIC PARAMETERS FOR ASSESSMENT OF. GESTATIONALAGE aste-59.7. Ultrasonographic Parameters for Assessment per timester a Gestational Sac Mean Diameter £7 days CCrown-Rump Length 5. Tdays Biparietal Diameter 10-11 days “ena Head Circumference ‘4 rimester ‘Abdominal Circumference Femurlength Femoral Length 2.3 weeks Biparietal Diameter Trimester Head Circumference Abdominal Circumference A, FIRSTTRIMESTER * Most accurate time to establish the correct 40G of the pregnancy Crown-Rump Length + Usually identified at 6 to 7 weeks AOG * Single most accurate measure of gestational age if done between 6 - 12 weeks AOG at +5 days 8. SECOND AND THIRD TRIMESTERS Biparietal Diameter (BPD) * Accuracy is greatest between 12-28 weeks AOG at + 10- 11 days, declining to = 3 weeks near term * Most accurate when the head shape is appropriately ovoid * Note: Check for Cephalic Index (Cl) prior to using the BPD © Clis the ratio of the BPD and Occiptofrontal Diameter (OFD) © Normal range (2:2 SD)is from 0.74 to 0.83 © If abnormal, may use other fetal parameters such as head circumference Head Circumference (HC) * HC=(BPD + OFD)x 1.57 * "Not affected by shape and is reliable from 11 weeks AOG Abdominal circumference (AC) * The growth parameter most commonly affected in pregnancies complicated by abnormal fetal growth patterns ; * Amacrosomic fetus will have an increased AC relative to gestational age and 7 asymmetrically growth-retarded fetus will have diminished AC measurement * The HCIAC ratio may be useful asa predictor of head-to-abdomen symmetry orasymmetry ‘Morder to identity the type of abnormal growth. Femur Length i le femuris the largest of the long bones, tert tely visualized and may be used to accurate m st moveable, easiest to image | a ly predict AOG from 14 weeks AOG unt 59, Esrasuistinc Ace oF Gestation | 317C. COMPOSITE AGING © Inaneffort to increase the accuracy of gestational age assessment, H; e eral Hadlock combined several measurements. Use of multiple Parameters asa method gestational age is valid when the gestational age estimates of the vatious u| parameter are similar, and hence assignment of gestational age am the parameters will improve accuracy © Ifthe gestational age estimates of one or several parameters is greater than 2 weeks different than the estimates of the other parameters, either the abnormal ultasound parameters should be excluded, ora different method should be used to estimate gestational age IV. _ NON-BIOMETRIC PARAMETERS A. Secondary Ossification Centers taBLe—s9.8. Secondary Ossification Centers based on AOG 2nd co work fe Of assessing Itrasoung ¥eFaQe Of ll the 318 | Latest o1achosmies a tHerapeumics Distal Femoral Ossification Center __| 32-33 weeks AOG ‘94% of patients at 34 weeks = 35 weeks AOG 35% of patients 2 35 Proximal bial plphycal Center [247 35weeksAO eae Proximal Humeral Epiphyseal 37-38 weeks AG 78% of patients a 38 weets Ossfication Center 8, Placental Maturity ‘TABLE-59.9. Grading of Placental Maturity Grade 0 ‘Smooth chorionic plate, no calcifications | Grade! With scattered calefications Grade increased basal and comma-likecaifications Grade i Extensive basal, cunilinear calefications from chorionic pate to base of placenta J C. Bowel/Colonic Echogenicity TABLE-59.10. Grading of Bowel/Colonic Echogenicity — ‘Abdomen uniform in appearance conde Colon notidentfied; <29 weeks AOG Golonic contents with echo-ree appearance identical to bladder and stomach Gradet " Colonic hausta identified Grade tl Intermediate; Colon appears more echodense than bladder but less than ver Grade I Colonic contents have echogenicity essentially equal to liver; >39 weeks AOGo, Small Intestinal Peristalsis sasue—59.11. Grading of Small Intestinal Peristalsis (and __| (Small intestinal peristalsis 1 + | Fewsporadic waves of small intestinal peristalsis in 3 discrete Grade areas, duration of 3 discrete areas, durations > seconds] [| Active waves of small intestinal peristalsis seen throughout Gadel! the observation interval; 37-38 weeks AOG | ¥, GENERAL GUIDE FOR GESTATIONAL AGE DETERMINATION «Theft day of LMP should be asked ofall pregnant women. They should be asked if they have egular menses, hae taken oral contraceptive pills within the ast 2 months, or have had any menstrual bleeding inthe fist trimester. The woman should be asked ifshe is certain of her LMP (but hiss stil not precise) * WF pregnancies should be dated by the date of embryo transfer minus 4 days to obtain LMP, and | ‘hen EDC by Naegele's rule. There sno need to ever change dating in these pregnancies. |r inst taresTeR (0-19 6/7 weeKs): if LMP and ultrasound based dating fer ty 2? days, preference should be given to the ultrasound based date ‘EARLY SECOND TRIMESTER (14 - 20 6/7 WEEKS): fLMP and ultrasound based dating Aiferby =10 days, preference should be given tothe ultrasound-based date LATE SECOND TRIMESTER (21 - 27 6/7 WEEKS): FLMP and ultrasound based dating ifr by 214 days, preference should be given tothe ultrsound-based date *ThiRO TRIMESTER (28 - 42 WEEKS): if LMP and ultrasound-based dating difer \_by221 days, preference should be given tothe ultrasound based date 59, EstaBuisHiNG AcE oF Gesrarion | 319FETAL SURVEILLANCE 1. GOALS OF FETAL SURVEILLANCE . To exclude fetal abnormality 2. To monitor the condition of the presumed normal fetus to determine the optimal delivery 3. Tomonitorstatus of fetal welkbeing in patients with the following medial or chstetic poi ‘TABLE-60.1. Medical or obstetric problems requiring close fetal surveillance sl FETAL Postterm pregnancy (>294 days,>42 weeks) | Decreased fetal movement | | Hypertensive disorders of pregnancy Intrauterine growth restriction Pre-pregnancy diabetes Oligohydramnios/polyhydramnios Insulin requiring gestational diabetes Multiple pregnancy Preterm premature rupture of Preterm labor membranes CChronic(stable) abruptio Iso-immunization ‘Abnormal maternal serum screening (hCG >2.0 MOM) in absence of confirmed fetal anomaly | Motor vehicle accident during pregnancy Vaginal bleeding Morbid obesity Advanced matemal age I. METHODS OF ANTENATAL SURVEILLANCE A. Fundal Height ‘© Measured along the abdominal wall from the top of the symphysis pubis tothe top ofthe fundus Correlates closely with gestational age in weeks between 20-34 weeks gestation © Used to monitor fetal growth and amniotic fluid volume B. Fetal Heart Sounds «Instruments incorporating Doppler (‘handheld Doppler’) ultrasound are often used which can detect heart sounds at 10 weeks © Standard nonamplified stethoscope can be used to detect heart sound at 20-22 weeks + Fetal heat ranges from 110-160 beats per minute . Sonography + Provides information regarding fetal anatomy, growth and well-being * Should be performed only when there isa valid medical indication and under the [ow possible ultrasound selting est 320. | Latest olaGnostics & THERAPEUTICSFETAL MOVEMENTS «pasts: Fetal movement decreases in response to hypoxemia and decreased amniotic fluid making fetal mavement counting a simple method of monitoring fetal oygenation and wel: being | PHYSIOLOGY 4. Passive unstimulated fetal activity commences as early as 7 weeks 2. Beyond 8 menstrual weeks, fetal movements are never absent for time periods exceeding 13 minutes 3, Between 20 and 30 weeks, general body movements become organized and the fetus starts, to show rest.activity cycles 4, Inthe third trimester, fetal movement maturation continues until 36 weeks, when behavioral states are established in 80% of normal fetuses | FOUR FETAL BEHAVIOR STATES quiescent state (quiet sleep) with narrow oscillatory bandwidth of the fetal hear rate frequent gross body movements, continuous eye movements, and wider oscillation of the fetal heart rate; analogous to rapid eye movement (REM) or active sleepin the neonate ‘continuous eye movements in the absence of fetal body movements and no accelerations ofthe heart rate; the existence ofthis slat is disputed vigorous movement with continuous eye movements and fetal heart accelerations; coresponds tothe awake state in infants Brag STATE 2F ey Are * Flues spend most oftheir time in states 1Fand 2 ‘Sleep-awake cycles are an important determinant of fetal activity and are independent of the maternal sleep- awake state; ‘sleep cyclicty"has been described to vary from 20 minutes to 75 minutes MI. CLINICAL APPLICATION OF FETAL MOVEMENT ASSESSMENT A. Methods to quantify fetal movement to prognosticate well-being |. Tocodynamometer 2. Visualization with real-time ultrasound 3. Maternal subjective perceptions * Most investigators have reported excellent correlation between maternally perceived {etal motion and movements documented with instrumentation © Fetal motions lasting >20 seconds were identified more accurately by the mother than shorter episodes * ACOG employs the “count to 10" method -a perception of 10 movements in 2 hours is considered reassuring 60. Ferat Survenwance | 321B. Fetal Movement Assessment All women WiTHOUT risk facoay ] 0 z Daily mmontoringcouninget fetal movements beginning 2128.32 weeks Al women WITHOUT risk facto Awareness of fetal movement beginning at 26-32 weeks and daily monitoring! counting of fetal movement if they perceive decreased fetal mavement Fetal movement <6 in 2hours | ae Pea Nonstress Test ] ‘Normal NST NO Risk Factors Continue with FMC | Normal NST WITH Risk Factors Clinical Suspicion of 1GRIoligohydramnios BPP or AFV within 24 hours Normal NST NO Risk Factors Continue with FMC Determine the future management and need for delivery based on ] ultrasound findings, NST findings and overall clinical picture *FMC- fetal movement counting; BPP biophysical profile; AFV-amniatic fluid volume; CST- contraction sess test NONSTRESS TESTING (NST) ‘© Basis: The heart rate ofa fetus who is not acidoticas a result of hypoxia or neurological depression, will temporarily acelerate in response to fetal movement. The NSTis primarily atest of fetal condition whereas the contraction stress test (CST) is a test of uteroplacental function. I. CRITERIA FOR NONSTRESS TEST (NST) REACTIVE >2 or more accelerations ocurrng within 20 minutes Prete Absent acceleration Less than 5 bpm oscillation NON HYPOXEMIC CAUSES: sleeping flus, prematurity, drug effects or CNS anomalies HYPOXEMIC CAUSE: Acidosis, fetal compromise Reassuring fetal welt being ‘Accelerations - abrupt (onset to peak in less than 30 seconds) increases in FHR above the baseline, of more than 15 bpm in amplitude, and lasting more than 15 seconds but less than 10 minutes + 232 weeks: acme of acelerations 215 bpm above the baseline ate; lasts 215 seconds (but <2min) | <32 weeks: acme 210 bpm for 210 seconds * The nonstrestest ofthe neurologically healthy preterm fetus equenty nonreactive: 50% at 24:28 wees 0G, 15% at 26.32 weels ADG.A 40-minute o longer tracing, to account or feta sleep cles, should be performed before concluding that there is insufficient fetal reactivity 322 | Latest omGNostics « THERareunicsNONSTRESS TEST per panel, notice the increase of fetal heat ate by more than 15 ited by the vertical marks (lower sno KJ, Bloom SL, Dashe JS, FIGURE~60.1. Reactive nonstress test. In the up} beatsmin for longer than 15 seconds following fetal movements, which are indica nel). From Abnormal Williams Obstetrics 25th ed. (p.513), by Cunningham F Lever Hofiman BL, Casey BM, Spong CY., 2018, USA: McGraw ill Education. followed by contraction tress test showing mild, formed, and the severely acidemic fetus could not by Cunningham F Leveno KJ, Bloom SL, Dashe ct fran BL Casey BM, Spang C¥.,2018, USA: McGraw-Hill Education. Fou ue Nonreactive nonstress tes (lef side of tracing) ations (right side of tracing), Cesarean delivery was pe bere Si rie From Abnormal Williams Obstetrics 25th ed. (p. 515), 60. Ferat Suaventance | 323324 . . NON-STRESS TESTS THAT ARE NONRE/ ABNORMAL NONSTRESS TESTS THAT RELIABLY FORECAST SEVERE FETALJEOPARDY |. SILENT OSCILLATORY PATTERN - fetal heart rate baseline oscillates <5 bpm; in. cate "indicates absent acceleration and beat to-beat variability, ominous finding “TERMINAL CARDIOTOCOGRAM” - associated with fetal growth restriction, oligahydramnios, fetal acidosis, meconium, and placental infarction 1. baseline oscillation <5 bpm 2. absent accelerations | 3. late decelerations with spontaneous uterine contractions ACTIVE FOR 90 MINUTES - almost invariably associated with significant perinatal pathology INTERVAL BETWEEN TESTING Originally arbiter set at 7 days based onthe fat hat anormal NSTis rede of goog perinatal outcome for one week. More frequent testing is advocated for women with post-term pregnancy, Type 1 diabetes, fetal growth restriction and pregnancy-induced hypertension DECELERATIONS DURING NONSTRESS TESTING Variable decelerations, if non-repetitive and brief (<30 seconds), do not indicate fetal compromise nor the need for obstetrical intervention Variable decelerations, if repetitive (23 in 20 minutes), even if mild, are associated with an increased rsk of cesarean delivery for fetal distress Decelerations lasting 21 minute have been reported to have an even worse prognosis CONTRACTION STRESS TESTING (CST) Asis: Uterine contractions transiently restrict oxygen delivery to the fetus; this can resulttoa hypoxic fetus that demonstrates recurrent late decelerations. The CST was: designed to unmask poor placental function, REQUIREMENT FOR CST: 3 spontaneous contractions of 40 seconds or longer are present in 10 minutes, no uterine stimulation is necessary. If <3 contractions in 10 minutes, contractions are induced with either oxytocin or nipple stimulation: OXYTOCIN CHALLENGE TEST -a dilute intravenous infusion is initiated ata rate of 0.5 mU! fin and doubled every 20 minutes until a satisfactory contraction patter is established Pr STIMULATION - the patient is asked to rub her nipple through her clothing for2 ne OF until a contraction begins; she is instructed to restart after 5 minutes if the first nipple stimulation did not induce 3 contractions in 10 minutes CONTRAINDICATIONS FOR CONTRACTION STRESS TEST Placenta previa Prior classical cesarean section Prior extensive uterine surgery Preterm labor High isk fo preterm labor Preterm rupture of membranes LATEST DIAGNOSTICS & THERAPEUTICSCRITERIA FOR INTERPRETATION OF THE CONTRACTION STRESS TEST Negative No late or significant variable decelerations Positive Late decelerations following >50% of contractions (even ifthe contraction frequency is <3 in 10 minutes) Equivocal suspicious Intermittent late decelerations or significant variable decelerations Fquivocal hyperstimulatory Fetal heart ate decelertions that occurin the presence of contractions mare frequent than every 2 minutes or lasting longer than 90 seconds Unsatisfactory <2 cm Targest single vertical pocket <2cm “may be omitted if all 4 ultrasound components are normal inter evaluation warranted, regardless of biophysical composite score, if largest vel savior The modified biophysical profile lies onthe "The BPS performed over 30 minutes and assesses fetal beh (afiasa measure of onger term oxygenation #82 measure of acute oxygenation, and the amniotic fluid index tical amniotic Mud pocket <2 40. Ferau Sunvewance | 325'V, MODIFIED BIOPHYSICAL PROFILE SCORE, INTERPRETATION, AND PREGNANCY | MANAGE. MENT re Prete tan Pea Ute 10/10 Normal nonasphyxiated fetus | No fetal indication fr intervention; epet test weekly except in diabetic patent ang postterm pregnancy (twice weekly) 8/10 Normal Normal nonasphyriated fetus | Nofetal indication for intervention, =a ‘AFI8I8 repeat testing per protocol Deliver 8/10 Abnormal AFI_| Chronic fetal asphyxia suspected GMONormal AFI | Possible fetal asphyxia WAPVabnormal, deliver. IF normal fluid at >36 weeks with favorable cervix, deliver. IF repeat test <6, deliver ifrepeat test >6, observe and repeat perpretocol | 40 Probable fetal asphyxia Repeat testing same day; if <6, deliver 02 ‘Almostcertainfetal asphyxia__| Deliver Doppler Velocimetry + Basis: Doppler ultrasonography is a non-invasive technique used to assess blood flow by characterizing downstream impedance. It gives information about uteroplacental blood flow and fetal responses to physiologic challenges. 1, | MOSTCOMMON VESSELS STUDIED BY DOPPLER A. Uteroplacental Function a. UTERINE ARTERY - progressive decrease in impedance with advancing gestation b. UMBILICAL ARTERY - low impedance circulation with increase end diastolic flow (EDF) with advancing gestation; increase in EDF reflects the increase in number of tertiary stem villi that takes place with placental maturation B. Fetal Function 4, MIDDLE CEREBRAL ARTERIES - high impedance circulation with continuous forward flow throughout the cardiac cycle; MCA <1 reflects brain-sparing reflex reflective of fetal hypoxemia; also used to assess degree of fetal anemia Descending Thoracic Aorta © Precordial veins: Ductus Venosus and Umbilical Vein |. INDICATIONS FOR UTERINE ARTERY DOPPLER AT 22-24 WEEKS AOG Previous obstetrical history Previous early onset gestational hypertension Placental abruption Intrauterine growth restriction . Silloth 326 | Latest owcnosnics 6 tHenapeunics‘sk actors in current Pre-existing hypertension pegnancy Gestational hypertension Preexisting renal disease Longstanding Type! diabetes with vascular Complications, nephropathy, retinopathy ‘Abnormal maternal serum screening (hCG or AF analy 19 (HCG or AFP >2.0 MoM) Il FREQUENCY OF BIOPHYSICAL PROFILE SCORING (BPS) BASED ON. ABNORMAL DOPPLERS Ee amas Saas Elevated indices only | Weekly Abnormal BPP or term or >36 weeks with no fetal growth a Twice weekly Abnormal BPP or >34 weeks of proven ‘maturity or convesion to REDV i Daily ‘Any BPP <10/10 or>32 weeks, Dexamethasone given sea Three times daily ‘Any BPP <10/10 or >28 week, Dexamethasone given *AEDY-absent end-diastolic velocity; REDV- reversed end-lastlicveloay; UVP - umbilical venous pulsations ‘Absent or reversed end diastolic low signifies increased resistance and itis uniquely associated with fetal growth ‘estiaion; such increased resistance to umbilical artery blood flows epartedto result om poorly vascularized pce vil ACOUSTIC SIMULATION TEST * Basis: loud external sounds are used to startle the fetus, provoking acceleration of the heart rate * HOW IS IT DONE? An artificial larynx is positioned on the matemal abdomen and a stimulus of 1-2 seconds is applied; this may be repeated up to 3 times for up to 3 seconds 5 INTRAPARTUM FETAL SURVEILLANCE * GoaL:To detect potential fetal decompensation and to allow timely and effective intervention to prevent perinatal/neonatal morbidity or morality * Basis: Changes in fetal heart rate precede brain i ne {etal heart patterns might be effective in preventing brain injury jury, hence, timely response toabnormal IE GUIDELINES FOR METHODS OF INTRAPARTUM FETAL HEART RATE MONITORING es Se LOW-RISK PREGNANCIES terten. auscultation ‘med after a contraction Sat fr 60 seconds ntnuous Literal lecronic monitoring enteral) = [1S minutes®? 30 minutes S minutes** 15 minutes ee "ably Set dtng andatera uterine contacto; Mg shige luation and charting at east evry 15 minutes; ‘*eluated at least every 5 minutes 60, Feta Sunvenuance | 327IL acai Maternal fever Chorioamnionitis Beta-adrenergic agonist Thyrotoxicosis Tachycardia (>160 bpm) CLINICAL SIGNIFICANCE OF ABNORMAL FHR ae — Heart failure | jovement Severe fetal ane Sepsis Hydiops Tachyanthythmias Local anesthetics Fetal bradyarthythmia Congenital heantbioc Bradycardia (<110 bpm) Hypotension Complete heart block Umbilical cord Hypothermia compression Hypoglycemia 2015 REVISED FIGO GUIDELINES ON INTRAPARTUM FETAL MONITORING aw latais NORMAL ad lets BASELINE 110-160 bpm Lackingatleastone— |[-<100bpm_ 525 bpm characteriticot Reduced vaebiliy, | VARIABILITY normality, butwith no | Increased vaiabilt pathological features | sinusoidal pattern No repetitive* Repetitive” late deceleraions or prolonged decelerationsfor>30 peas min(or>20minif reduced variability), Decelertion >Smin_| INTERPRETATION No hypoxiaacidasis | Low probability of High pbaiiyef hhypoxialacidosis hhypoxilacidess No intervention necessary | Action to correct reversible | Immediate actionto | toimprove fetal causes if identified, correct reversible cause, onygenation state close monitoring of adjunctive methods, or | CLINICAL NANAGEMENT adjunctive methods if hiss nt possible expedite delivery In acute situations immediate delivery | should be accomplished | *Decelertions are repetitive when associated with >50% contractions Absence of accelerationsin labours of uncertain significance IV, _ DIFFERENTTYPES OF VARIABILITY ssa) iia No detectable variations around baseline | Mini bpm from baseline [Moderate [6-25 bpm from baseline ____[>25bpm fiom baseline 328 | LATEST DIAGNOsrICs & THERAPEUTICS Pa ena aes Non reassuring fetal status; Hypoxemiafacdosis: fetal sleep cycles; drugs; prematurity; pre-existing | neurological abnormality; congenital anomalies a(MANAGEMENT CLASSIFICATION OF VARIABLE DECELERATION v Presario COMPRESSION asd Ped May consider altering pushin Nuchal cord efforts to allow more: ince between contractions Gigohydramnios Earlyin labor ‘Amnicinfusion r Sudden onset often atthe ime | Elevation of presenti 5 ig part, Card proaps of membrane rupture immediate cesarean section Tnusual cord compression Variable timing and shape Repositioning «short cords + other cord entanglement ue knots Vi. CLINICAL SIGNIFICANCE OF DECELERATIONS Ed uuu aos ba Early Mirror images of contractions Head Benign gradual decreases in FHR below the | compression baseline beginning and ending simultaneously with uterine contractions Variable relations to contractions | Umbilical cord | Mayindicate ‘an abrupt decrease in FHR below compression | acidotic he baseline of at least 15 bpm fews with onset to nadirof less than 30 seconds late Uteroplacental | Always Delayed in elation to uterine insufficiency | worrisome contractions gradual decrease in FHR below the baseline with onset to nadir of at least more than 30 seconds Always Visually apparent decrease in worsome the FHR below the baseline decrease in FHR from the baseline thatis 215 bpm, lasting 22 minutes but <10 minutes in duration; tf a deceleration lasts 210 minutes itis a baseline change 60. FevarSuavenuance | 329