CH 10 ANTEPARTUM FETAL ASSESSMENT Some definitions: Alpha fetoprotein (AFP) plasma protein produced by fetus Surfactant combo of lipoproteins

teins produced by lungs of mature fetus to surface tension in alveoli, thus promoting lung expansion after birth Phosphatidylglycerol (PG) major phospholipid surfactant whose presence in amniotic fluid indicates fetal lung maturity Lecithin/sphingomyelin ratio (L/S) ratio of two phospholipids in amniotic fluid used to determine fetal lung maturity; ratio of 2:1 or greater usually indicates fetal lung maturity Neural tube defect congenital defect in closure of bony encasement of spinal cord or skull; includes defects such as anencephaly, spina bifida, etc Intrauterine growth restriction (IUGR) due to insuff. Perfusion through placenta, causes fetal growth; may be caused by maternal diabetes, HTN, or smoking) Multiple marker screening analysis of maternal serum for abnormal levels of alphafetoprotein, hCG, and estriols that may predict chromosomal abnormalities of fetus Amniocentesis transabdominal puncture of amniotic sac to obtain sample of amniotic fluid that contains fetal cells and biochemical substances for lab tests Amniotic fluid index (AFI) ultrasound in which vertical depth of largest fluid pocket in each of 4 quadrants of uterus is measured and totaled Biophysical profile (BPP) method for evaluating fetal status during antepartum period based on 5 variables originating w/fetus: FHR, breathing movements, gross body movements, muscle tone, amniotic fluid volume Chorionic villus sampling (CVS) transcervical or transabdominal procedure to obtain sample of chorionic villi (projection of outer fetal membrane) for analysis of fetal cells Contraction stress test (CST) method for evaluating fetal status during antepartum pd by observing response of FHR to stress of uterine contractions that may induce recurrent episodes of fetal hypoxia Non-stress test (NST) method for evaluating fetal status during antepartum pd by observing response of FHR to fetal movement Percutaneous umbilical blood sampling (PUBS) procedure for obtaining fetal blood through ultrasound-guided puncture of umbilical cord vessel to detect fetal problems such as inherited blood disorders, acidosis, infection Vibroacoustic stimulation use of sound stimulation to elicit fetal movement and acceleration (speeding up) of FHR ASSESSING RISK FACTORS Biophysical factors originates from mother or infant and impacts pregnancy o Maternal diabetes, HTN, autoimmune disorders Psychosocial factors bipolar, depression, smoking, alcohol, drug use Sociodemographic factors access to prenatal care; maternal age (< 16 or >35), parity, income, immigration status; inadequate prenatal care (initial visit after 20 weeks) Environmental factors exposure to chemicals, radiation, pollutants 1

INDICATIONS FOR FETAL DIOGNOSTIC TESTS To detect congenital anomalies To evaluate condition of fetus ULTRASOUND Purpose o Often done w/1st prenatal visit to better date pregnancy w/LMP date and ID possible abnormalities o Crown-rump length measured (CRL), measures length of fetus First trimester ultrasound o Confirms pregnancy and verifies loc. Of preg (ex: uterine or ectopic) o Detects multiple gestations o Gives idea of gestational age, CRL and head measurements CRL most reliable indicator of gestation age at this time o Determine loc of uterus, cervix, placenta for procedures (ex: CVS) o Done transvaginally Probe inserted into vagina Embryo can be seen 5 6 weeks nd 2 trimester o Confirm due date o Confirm gestational age (less accurate after first trimester) o Better idea of placenta location o ID markers which suggest abnormalities o Done transabdominally Requires full bladder to lift uterus up and out of pelvic cavity 3rd trimester o Done in conjunction w/biophysical profile, amniocentesis Levels of obstetric ultrasound o Standard general survey of fetus, placenta, AFV o Specialized done of abnormalities found during standard scan or w/lab or test results o Limited done to address specific question (ex: fetal presentation) Advantages o Non-invasive, comfortable for mother o Clear visibility of fetus and surrounding structures, immediate results Disadvantages o Cannot ID all defects of fetus and surrounding structures/function Interpretation of results o Radiologist, nurse midwife, or OB reads immediately

DOPPLER ULTRASOUND BLOOD FLOW ASSESSMENT Ultrasound to determine rate of blood flow through umbilical cord and placenta Indication o Pregnancy complicated by HTN or fetal growth restriction o Usually done when IUGR suspected (due to insufficient perfusion of placenta) When and how performed o 2nd or 3rd trimester o Ultrasound detects Doppler shift Indicates forward movement of blood flow w/in vessel Advantages - Non-invasive Disadvantages findings are not diagnostic ALPHA-FETOPROTEIN (AFP) SCREENING AFP is predominant protein in fetal plasma and is synthesized by embryonic yolk sac, developing fetal liver, and GI tract Diffuses from fetal plasma into fetal urine and is excreted into amniotic fluid Present in amniotic fluid but also crosses placental membranes into maternal circulation o Maternal serum alpha-fetoprotein (MSAFP) o Amniotic fluid alpha-fetoprotein (AFAFP) Purpose o Screening for developmental defects Low levels MSAFP indicate chromosomal abnormalities (ex: Down Syndrome) Elevated MSAFT indicates neural tube defects (NTDs) (ex: anencephaly, spina bifida, ventral abdominal wall defects) When and how performed o 16 18 weeks gestation o Blood drawn and analyzed for MSAFP Obese women might have inaccurate low MSAFP bc serum dilution Thin women might have inaccurately elevated levels MULTIPLE-MARKER SCREENING Purpose o Screening for chromosomal abnormalities When and how performed o 16 18 weeks gestation o Blood drawn and analyzed for MSAFP, hCG, unconjugated estriol Positive results if: MSAFP, estriol, hCG o Placental hormone inhibin A can also be tested as a 4th marker for improved accuracy to ID trisomy 21 in women < 35

CHORIONIC VILLUS SAMPLING (CVS) Purpose o Chromosomal, metabolic, genetic makeup analysis of fetus When and how performed o 10 12 weeks gestation o Chorion (fetal tissue) from fetal side of placenta is aspirated and analyzed for chromosomal, metabolic, genetic abnormalities NOT used to detect NTDs (require amniotic fluid sample) o Done transvaginally or transabdominally w/ultrasound guide Advantages can be done earlier than amniocentesis Risks infection, bleeding, rupture of membranes, fetal loss o Assoc. with risk of fetal loss than amniocentesis Interpretation of results o ~2 weeks for results o Chrom. Analysis ~3 days o Results may require further testing w/cells obtained by amniocentesis AMNIOCENTESIS Purpose o Amniotic fluid is aspirated and analyzed for diff things depending on when performed o Done w/advanced age, hx genetic disorders, (+)AFP test When and how performed o 14 20 weeks gestation o Ultrasound guides placement of needle through maternal abd wall and into uterine cavity Midtrimester amniocentesis o ID chrom abnorms, met defects, NTDs o Evaluate fetal condition when mother is sensitized to Rh(+) blood o Diagnose intrauterine infections o Investigate AFP when maternal multiple-marker test is not normal Third trimester amniocentesis o Determine fetal lung maturity AF tested for L/S ratioRatio of 2:1 is indicative of fetal lung maturity AF tested for PG presence indicates maturity Advantages actual chromosomes to analyze Risks infection, bleeding, rupture of membranes, fetal loss, amniotic fluid loss o Apply pressure when needle is removed o Instruct mom to watch for amniotic fluid leakage (vaginally), uterine contractions, bleeding

PERCUTANEOUS UMBILICAL BLOOD SAMPLING (PUBS) Purpose o Analysis of metabolic, chrom, hematological disorders and fetal infections o Depends on indication o When and how performed Using Umbilical vein (1) carries oxygenated blood Umbilical arteries (2) carry deoxygenated blood Advantages direct fetal blood sample Risks bleeding from vessel, fetal hemorrhage, fetal bradycardia ANTEPARTUM FETAL SURVEILLANCE 3 goals: o To determine fetal health or compromise as accurately as possible o perinatal morbidity and mortality o Guide interventions by OB team Non Stress Test (NST) o Purpose Uses external fetal monitor to determine fetal well-being Determines whether fetus can or cannot tolerate activity based on HR during fetal movements Examines ability of FHR to in assoc w/movement o Indications Suspected fetal distress IUGR may be suspected Due to Anything that affects circulation and causes perfusion o Diabetic or hypertensive mother o When and how performed 2 belts placed on mothers abd 1 detects FHR 1 detects fetal movement o Interpretation of results Reactive result (normal) = fetus moves FHR FHR 15 beats x 15 seconds twice in 20 min o FHR 15 beats above baseline for 15 seconds twice in 20 min Non-reactive result (abnormal) = FHR does not increased w/movement FHR in 40 min If non-reactive after monitoring for 20 min, monitor for another 20 min o If still no , result is non-reactive Vibroacoustic stimulation test (VST) o Purpose To confirm non-reactive findings of NST o when and how performed 5

same as NST except stimulus provided practitioner determines where fetal head is and uses artificial larynx to give stimulation and vibration for up to 3 seconds o interpretation of results reactive or non-reactive (same as NST) Contraction Stress Test (CST) o Purpose ID fetus at risk for compromise May be referred if non-reactive NST o When and how performed Induce light contractions to see how fetus tolerates stress of contracting uterus Contractions induced by IV oxytocin or breast self stimulation (BSS) o BSS palms of hands to stimulate breasts for 2-3 min release of oxytocin naturally Same set up as NST and VST FHR, fetal activity, contractions all monitored o Interpretation of results Uterus contracts FHR and when contractions end FHR back to baseline o High false positive rate Biophysical Profile (BPP) o Purpose Evaluate fetal response to activities controlled by CNS o Indications concerns of placental insufficiency, fetal hypoxia, maternal diabetes or HTN o when and how performed NST for 30 min with ultrasound 5 components Fetal breathing movements (at least 1 episode of 30 seconds) Gross body movements (3 or more) Fetal tone (how well fetus extends extremities) (at least 1 flex/extend) AFV (determined by ultrasound) (expect adequate fluid volume) FHR (expect reactive to movements, FHR) o Interpretation of results Each component worth 2 points Reassuring result = 8 or 10 Equivocal result = 6 o May need further assessment; early delivery anticipated Non-reassuring = 4 or less o Requires additional assessment

Modified BPP 6

Purpose Combo of NST and amniotic fluid index (AFI) Gives info abt long germ placental function o Interpretation of result AFI should be > 5, NST should be reactive AFI < 5 = indicative of oligohydramnios AFI > 18-20 = hydramnios Maternal assessment of fetal movement (kick counts) o Purpose ID hypoxic fetus o When and how performed 28 weeks gest and on Track fetal movements for 1 2 hrs per day o Interpretation of results Reassuring = 10 movements in 2 hr period (at least 4 in 1 hr) If baby isnt moving as much, suggestive of problem Further testing may include NST or BPP

CH 10 review questions 1. What is the difference btwn chorionic villus sampling and amniocentesis? a. CVS sample of tissue from fetal side of placenta tested at 10-12 weeks to detect genetic, metabolic, DNA abnormalities b. Amnio sample of amniotic fluid tested at 14 20 weeks to detect same as above in addition to NTDs 2. Daily fetal movement counts are done to ID hypoxic fetuses 3. What conditions are suggested by AFP levels that are low a. Chromosomal abnormalities 4. What conditions are suggested by AFP levels that are high a. NTDs, anencephaly, ventro-abd wall defects 5. Which test will likely be recommended subsequent to an AFP level? Why? a. Amniocentesis to get more accurate results 6. Purpose of NST is to evaluate ability of FHR to accelerate w/fetal movement 7. 16 week gravida schedule for abd US during pregnancy. Appropriate teaching related to this: a. She must drink 1-2 quarts of water before procedure bc full bladder lifts uterus up and out of pelvic cavity for viewing 8. Basic principle of CST is to observe response of FHR to stress of uterine contractions 9. Fetal heartbeat should be visible on US by 8th week following LMP 10. Woman assessing fetal movements each day should notify OB if < 12 movements occur that day 11. During fetal hypoxemia, blood is shunted away form kidneys and lungs towards brain. This hypoperfusion to kidneys results in amniotic fluid volume (oligohydramnios) (bc perfusion to kidneys urine output) 12. Amy, 15 yo G1P1 gravida is 35 weeks and has been diagnosed w/severe preeclampsia. Due to her condition, early delivery is being considered. Which test do you expect to be ordered, why? Amnio to test for maturity of fetal lungs Test is performed; results show PG is present. What does this indicate? Fetal lung maturity What will Amys care now entail? Prep for C-section, pre and post op teaching