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OB Lecture 3 - NON–INVASIVE ANTEPARTUM FETAL - Temporary ↓ in FM

SURVEILLANCE
USTMED ’07 Sec C - AsM - Because of increased maternal
carboxyhemoglobin levels or direct effect of
nicotine on Fetal CNS
Antepartum Fetal Surveillance
Definition - All methods to monitor fetal well being before labor
Electronic Fetal Heart Rate Monitoring
Administered :
1. age of gestation when fetal survival possible
2. When neuro developmental center is already operative

Antepartum Fetal Surveillance Methods


Non-Invasive Invasive Non- Stress Test
Fetal Movement Counting Amniocenteses - Basis :
Non-Stress Test Chorionic Villus Sampling
Contraction Stress Test Fetal Blood Sampling
 Fetus with good integration of PNS, SC , brain and
autonomic NS and intact myocardium will respond
Biophysical Profile Scoring
to FM with accelerations
Doppler Velocimetry
- Interpretation:
Fetal Movement Counting
- Simple
- Reactive – 2 FM in 20 min. , FHR accels. 15
bpm.,15 secs. , variability 6bpm. N baseline
- Least Expensive
- Second half of pregnancy - Non-Reactive – (-) FM, (-) acceleration w/
movement or stimulation, poor or (-)LTV, baseline
- Basis : N or abn.
 Compromised fetus ↓ O2 requirements by reducing - Uncertain Reactivity - < 2 FM in 20 min. or accels
activity of < 15 bpm.,<15 secs., LTV < 6 bpm. Abn.
Baseline
 ( + ) correlation between maternal perception of
fetal movements and movements by US scanning
for 28-43 wks.
 Documented cessation of fetal activity warns of
impending death

- Method:
 Most attractive and convenient “ count to 10”
 Performed at any convenient time
 Patient Left lateral , concentrate on fetal activity Reactive Non-reactive

 Evening hours, recent meal not necessary - Reactive Test - good fetal well being for 1 week or
 Father help in charting promote family more in > 99% of cases.
attachment and compliance
- Non- Reactive Test – poor fetal outcome (perinatal
- Fetal Kick Count Chart death, Low 5 min. AS, late decels.) in < 20 % cases
 Contact physician if >1 hr to feel 10 movements - Uncertain Reactivity- repeat NST, back-up BPS, CST
depending on clinical condition or OB judgement.
- Limitations of Fetal Movement Counting
1. Patient Comprehension and Convenience - Limitations of NST
 Clear instructions mandatory 1. Fetal Sleep State
- Fetal sleep state affects fetal
 Educational attainment and socioeconomic
cardioregulatory center, periodic variation in
background
variability
 Problem of compliance before advent of “
Count to 10 method” - Periods of quiet sleep last for 1 hr. extend
2. Failure to anticipate certain stillbirths: observation time to eliminate possibility of
 No technique can anticipate stillbirths fetal sleep state
- OFFSET LIMITATION
 When FMC reassuring , still births may be due
to acute hypoxic changes (abruptio placenta,  “10-20-40” rule
umbilical cord compression) - Extension to 90 min. improve false (+) rate
3. Failure to detect growth abnormalities: - Fetal inactivity may be prolonged up to 1 hr.
- Diminished activity only in the most severe
cases of IUGR < 5h percentile 2. DRUGS
( Matthew,1975) - Increase FHR
Mechanism Example
4. Failure to detect malformations:
B-adrenergic Ritodrine
- Most fetuses w/ congenital anomalies show
stimulation Terbulatline
normal fetal movement patterns
Isoxuprine
- Fetuses w/CNS anomalies (hydrocephalus) or Increase Metabolic rate Caffeine, Thyroxine
restriction of the LE (congenital hip CNS stimulants Cocaine, Ketamine
dysplasia) ↓ FM (Rayburn, 1985) Vagal Blockade Atropine
5. Failure to distinguish bet multiple pregnancies: Paracatechol Stimulants Ephedrine
A-adrenergic blockade Phentolamine
- Technique cannot distinguish between twins
on daily basis. - Decrease FHR
- Mother cannot determine which of the Mechanisms Example
fetuses are less active. Vagal Stimulation/SA Digoxin
6. Drugs Myocardial depressants Lidocaine
B-sympathetic blockade Propanolol
- Depressant drugs: barbiturates,
CNS depressants General anesthetics
benzodiazepines, narcotics, methadone,
alcohol  ↓ FM
3. Maternal Conditions:
- Day2 of Bethamethasone administration FM ↓ - Thyrotoxicosis , Hypokalemia – baseline FHR
49% all values return to normal variability
 Day4 transient effect
7. Smoking: - Maternal dehydration - ↑ FHR
- Maternal fever - ↑ fetal core temp.; ↑ FHR
- Test Reliability of CST
4. Fetal Conditions:
- Congenital Anomalies –heart block,
- (+) CST poor predictive value < 35%
- Management depend on:
anencephaly
1. age of gestation – Preterm , BACK-UP
5. Gestational Age:
BPS or Doppler. Term or Post term
- “Physiologic non-reactivity”
DELIVER
- NST in preterm infant :
2. Maternal Condition
 15bpm amplitude not typical
 < of organized fetal arousal states Biophysical Profile Scoring
(state F) common quiet sleep states - Basis:
(state 1F)  Hypoxia Cascade
Embryogenesis
 Low amplitude decelerations seen Fetal CNS centers
with FM FT Cortex/subcortical 7.5-8.5
(tone) area wks
 FHR ↓ in both rest and activity
FM Cortex-nuclei 9 wks
periods with↑ in AOG (movement)
- Extend testing time and modifying criteria to FB 4th ventricle 20-21
10 bpm/accelerations reduce False (+) rate (breathing) wks
of NST. FHR Post. 24 wks Hypoxia
(heart rate) Hypothalamus
- NICHD ,1997 Research Guidelines for
medulla
Interpretation of FHR:
 < 32 weeks –accelerations in
preterm fetus is >/= 10 bpm. , >/=
10 secs.
6. Poor predictor of chronic asphyxia: - Two categories:
- non- visualization of Amniotic Fluid 1. Acute biophysical variables:
- must be combined with BPS or AFV - altered immediately in the presence of fetal
measurement hypoxemia
- Clinical Efficacy of NST - FB, FT,FM, HEART RATE (NST)
2. Chronic Biophysical Variables:
- High False (+) Rate  80%
- Non-Reactive Test FURTHER EVALUATION
- requires a period of time before alterations
become visible Amniotic Fluid Volume – Fetal
(BPS , CST)
compensatory mechanism  Blood flow
directed to essential organs (Brain, Heart,
Contraction Stress Test
Adrenals) non-essential organ (Kidney)
- Basis:
- Marginally compromised fetus w/ limited O2
-   Amniotic Fluid Volume
reserve and limited placental function manifest
- Methodology:
w/ late decelerations when subjected to uterine
contractions. - curvilinear scanner
- Initial survey:
- Methodology: a. Fetal #,lie ,position
- Same with NST , 20 min. recording of FHR b. Placenta
c. Fetal morphometric data ( BPD,AC,FL)
and uterine activity.
d. Gen. Survey
- (-) Uterine contractions :
1. IV Oxytocin 3 cxns. In 10 mins. - Fetal Tone, Fetal Movement, Breathing, AFV
2. Nipple stimulation ( cost-effective , combined with NST for Full BPS , (-) NST Modified
shorter testing time. - Biophysical Profile Scoring
Variable Score 2 Score 0
 1 nipple x 2 min. , rest 5 min. Fetal 30 sec. Sustained Breathing < 30 sec. Of fetal breathing
Breathing Movements movements in 30 mins.
In 30 min.
- Interpretation of CST Fetal 3 or > Gross Body Movements in 2 or < gross body movements in
- Negative – (-) Late decelerations or Movements 30 min.
Simultaneous limb and
30 min.
observation
significant variable decelerations Trunk movements
- Positive – Late decelerations ff. by 50% or >
Fetal Tone 1 episode of motion of a limb fr.
Position of flexion to ext. w/
Semi or full limb extension w/
no return or slow return to
if frequency is < 3 in 10 min. return flexion
Fetal Heart FHR accels 15/bpm. Lasting for (-) accelerations or < 2
- Equivocal Suspicious – Intermittent late or Rate 15 secs. W/ FM for 20 min. Of FHR in 20 min.
significant VD present in one contraction AFV AF pocket 1 cm. In 2 AF pocket < 1 cm. In
planes 2 planes
- Equivocal Hyperstimulatory – FHR decels. in
cxns. > 2 min. or > 90 secs. - BPS Interpretation
- Unsatisfactory - < 3 cxns. In 10 min. or
BPS Score
10
Interpretation
Normal Non-
Management
(-) indication for delivery weekly testing
uninterpretable trace asphyxiated DM 2 x a week
8/10 N AF 8/8 Normal Non- (-) indication for delivery Rpt. Test /protocol
asphyxiated
8/10 ↓ AF Chronic fetal DELIVER
asphyxia
suspect
6 Possible fetal AF abn. DELIVER
asphyxia <36 wks. N AF Cx favorable Deliver, if < 36 wks.
LS ration<2 ,Cx unfavorable , rpt.test in 24 hrs. ,
rpt. Test < Deliver
>6 Observe
4 Possible fetal Rpt.test same day < 6 deliver
asphyxia
0 to 2 Almost certain DELIVER
asphyxia
CST (+) CST (-)
- Modifications in BPS
- Limitations of CST
 Selective use of NST when all other 4 variables are
- Same limitations as NST
normal
- Limited application :
 Substitution of AFI for vertical pocket
 Multiple Pregnancy
 NST/AFI – complete BPS for abn. NST or AFV
 Preterm Labor
 Hx. Of Uterine Rupture  BPS & Placental Grade – scoring 3 for intermediate
 Placental Abnormalities variable VAS
 Classical CS scar
- Timing and Frequency of BPS 7. Polyhydramnios
 Time and frequency variable Individualized - Maternal Diseases w/ polyhydramnios (DM,
approach  “ Disease specific testing “ Multiple Pregnancy, Hydrops) cannot be
 Testing not started at AOG where active assessed because no score,only in
intervention not possible oligohydramnios
 More immature fetus more abnormal score to 8. Inability to provide an estimate of fetal reserve
warrant delivery - Waxing and waning of BPS parameters in
 Take into consideration maturation of CNS centers sustained hypoxemia indistinguishable fr. N
BPS activities. This is because of fetal
- Limitations of BPS compensation & resetting of sensitivity.
Sudden insult (abruptio), superimposition of
1. Fetal rest activity cycles: 2nd insult ( uterine cxns.)
 Fetus variation in sleep states average 20-30
- Test Reliability:
min. more pronounced with fetal maturity
 REM stage – FB present 30-75% of time, apnea
- Corrected Perinatal Mortality Rate: 0 –
26.4/1000
pds. brief, GBM more frequent, FT diminished
- False (-) rate : 0.078-2.28
 Non- REM –FB 14- 35% ,apnea pds. long so
that if < 30 min. observation of absent FB - The average interval between last normal
may not be due to hypoxia FT increased, GBM score and fetal death was 3.62 days
diminished (placental & cord accidents)
2. Maternal Glucose level:
Doppler Velocimetry
 ↑ incidence of FB after meals.
 ↑ in FB in the 2nd. & 3rd hr. after a 800kcal.
Meal during the last10 wks. of pregnancy
 No association with meals and incidence of
GBM and FT.
3. Gestational Age:
 FB seems to ↑ with advancing AOG 24-28 wks.
–14% of time , 19 wks- 6%, 10 wks- 2%
 GBM & FT – move more often at earlier AOG ,
more sporadic and shorter
4. Alcohol and Smoking:
 FB– inhibited by alcohol , 20 oz. Of alcohol in
Doppler Shift
healthy pregnant women inhibit FBM x 3hrs
not reversed by glucose - Spectral analysis:
 Smoking –controversial 1. Quantification of flow – unreliable
• 2 cigarettes ↓ FB 2. Doppler wave form analysis – waveform from an
• ↓ in rate but not incidence arterial source represent arterial velocity
waveform and is configured by upstream and
• Nicotine – effect on uterine vasculature downstream circulatory factors.
causing fetal hypoxemia, direct effect
on fetal respiratory drive GBM & FT – not
affected by Smoking and Alcohol
5. Labor:
 FB – initial fall in the rate with Braxton Hicks
cxns. With ↑ after
 incidence ↓ during last 3 days prior to onset
of labor and during latent phase, abolished
during active phase
 GBM & FT – no effect
6. Drugs
↓ FBM ↑ FBM
Anesthetics Cathecolamines Wave Form Analysis
halothane, adrenalin, B mimetics
Arterial Venous Other
thiopental Adenylcyclase inhibitors Umbilical Ductus Venosus Coronary sinus
Barbiturates Prostaglandin synthetase MCA Inferior Vena Cava Coronary arteries
Narcotics – morphine inhibitors –indomethacin Uterine Pulmonary artery
Aorta
Benzodiazepines Doxapram Renal Artery
Prostaglandin Internal Carotid
Pancuronium Artery

- Limitations of Doppler Velocimetry


Drugs – Fetal Movement 1. Use as a primary antepartum surveillance test
Drug Effect limited ( IUGR, DM,SLE, APAS )
Inhalational anesthetics Abolition of FM o ALERT signal of possibility of fetal
(Halothane) compromise associated with placental
Neuromuscular Blocking Abolition of FM pathology
Agents (pancoronium) o Utilize other tests ( BPS, NST, CST)
Narcotics Reduced FM o Beginning of a spectrum NOT a pt. Where
Neuroepileptics Variable effect morbidity appears
Steroids Transient decrease o Mean duration of Dx. Of AEDV to onset of
fetal distress 6-8 days
Drugs – Effect on FT 2 High quality equipment and trained personnel
Drug Effect
Neuromuscular Blocking Agents ↓ in flexor tone 3 Inability to predict stillbirths related to acute
Phenobarbital & Benzodiazepines ↓ in flexor tone changes in maternal fetal status (placental and
cord accidents)
Narcotics to the mother (-) effect
4 Drugs:
Drug Effect
Terbutaline & Ritodrine ↓ S/D ratio UA, Uterine Artery
MgSO4 ↓ MCA indices
Steroids:
Dexamethasone
Betamethasone ↓ PI in MCA

- Interpretation and Management Guidelines


o Umbilical Artery Doppler weekly
o Abn. Doppler studies useful in determining
frequency of other tests
o Abn. Doppler studies < 32 weeks look for other
evidences of fetal compromise
o > 32 weeks, prior to term deteriorating Doppler
studies (AEDV, REDF) may be indication for
delivery.
o *** Take into consideration ALL clinical factors

- Umbilical Artery
- CT Significant ↓
in CS for fetal
distress (-) effect
on perinatal
mortality

Umbilical Artery Flows

- Cochrane Pregnancy and Childbirth Group, 2002


- 11 RCT’s N = 7000
- HR with doppler vs. HR w/o Doppler
- Results:
• ↓ perinatal deaths (OR .71, 95%CI 0.50 – 1.01)
• fewer induction of labor (OR .83 95% CI .74-.
93)
• fewer hospital admissions (OR .56 95% CI .43
-.72)
- Conclusion:
 Use of umbilical doppler in HR pregnancies
improve outcome and reduce perinatal
deaths

Conclusion
1. Methods and Limitations
2. NO tests superior
3. INTEGRATE whole clinical picture !! - fin -
AsM audrey_cl@yahoo.com