ANTEPARTUM FETAL

SURVEILLANCE
Achala Sahai
 Definition

Timely detection of morbid changes in the

fetal status followed by adequate
interventions to avoid death or disability of
fetus or neonate.
 Limitations

• No ideal single test is available to detect

all fetal problems that too timely : delayed
interventions have no beneficial effects
• None of the tests is 100% specific
generalised use False positive tests
unrequired untimely interventions
Iatrogenic preterm delivery Increased
neonatal morbidity
 Current Methods : Biophysical

• Fetal movement count

• NST
• CST
• Fetal BPP
• Modified BPP
• Fetal doppler ( umbilical, cerebral,uterine
and venous )
 Fetal Movement Count

• Mother assesses frequency of FM

• Rationale: Good correlation b/w FM perceived by
mother & FM detected by US b/w 28-43wks
• Simplest, least costly in II half of pregnancy
• Subjective variability in the perception of
movements:
1. maternal obesity
2. Excessive amt. of amniotic fluid
3. Ingestion of medications

contd…
 Traditionally

Maternal perception of FM Decrease or cessation

Indication of fetal wellbeing Fetal compromise

• MC used method: ‘Cardiff Count of 10’

 10 FM in 10 hrs or less : good fetal health
 < 10 FM in 10 hrs or 10 FM occur in double the
usual no. of hrs : Further evaluation
• MC causes of test failure :
 Maternal noncompliance
 Untimely late reporting of decreased FM
 Fetal Movement Count

• Out of all movements about 70-80% are

perceived by mother.
• Maximum 30 movements can occur
• Peak activity : 9.00 p.m. to 1.00a.m.
(period of low maternal plasma glucose
level)
 Non Stress Test

• First line test for primary fetal surveillance

• Advantages:
 Noninvasive

 Easily performed & interpreted

 Readily accepted, no contraindications

• Basis/Rationale of Test:
FM Cerebral cortex Temporary acceleration of FHR
• Factors affecting brain absence of FHR accel.:
 Physiologic: sleep
 Drugs
 Pathologic : Fetal hypoxia
 Non Stress Test
How to Perform?

Semi fowler’s position B.P. Monitoring

Tococardiographic equipment Observe for 10 min.
Instruct the patient Reactive test +/- No
spontaneous FM in initial 20 mins Repeat test
with external manipulation to provoke FM for next
20 mins No acceleration in 40 mins. Non
reactive NST
 Non Stress Test : Results

• Reactive (normal) : Two or more FHR

accelerations of at least 15 bpm lasting for
at least 15 seconds in a 20 mins. period
with or without association with FM
• Nonreactive : Lack of acceleration for a
period of 40 mins.
• Unsatisfactory/Equivocal NST : Quality of
tracings inadequate for interpretation.
 Non Stress Test: Effect of
gestational Age

• 24 -28 wks : 50% of NSTs are nonreactive

• 28 -32 wks : 15% of NSTs are nonreactive
even in healthy uncompromised fetus
 Non Stress Test:False negative
rate

• Reactive NST in distressed fetus

• 3.2/1000 .
• Fetal death or serious morbidity following
reactive NST is very low.
• Twice weekly NST : 1.9/1000
• Frequency of stillbirths with weekly NST:
6.1/1000
Non Stress Test: False positive rate

• Nonreactive result in normal fetuses

• 50% for morbidity, 80% for mortality
• Serious fetal problems with nonreactive tests : very low
• Additional corroborative testing / use of adjunctive tests
before any intervention is must.
• May be decreased if interpretation of NST includes other
variables baseline FHR, Variability of FHR, presence or
absence of accelerations & decelerations.
• Nonreactive NST + Normal FHR variability + / absence
of decelerations False positive test
• Nonreactive NST + poor FHR variability + / decelerations
Fetal hypoxia
 Non Stress Test Interpretation:
Other Important Variables

Baseline Heart rate : 110-160 bpm

• Tachycardia : > 160 bpm
• Bradycardia : < 110 bpm
• MC d/t : 1. Maternal medication
2. Maternal temparature
• May be d/t: Fetal hypoxia
 Non Stress Test Interpretation:
Other Important Variables

• FHR Variability : 5bpm

• Interactions of sympathetic and parasympathetic
nervous system
• Affected by: 1. Gestational age
2. Maternal medications
3. F. Congenital anomalies
4. Fetal acidosis
5. Fetal Tachycardia
 Non Stress Test Interpretation:
Other Important Variables

• FHR Accelerations : 15 bpm, 15 sec., 20

min. with FM/fetal stimulation
• Sign of fetal health
• Frequency increases as pregnancy
approaches term
• Absence : MC d/t fetal sleep, may be sign
of fetal compromise
 Non Stress Test Interpretation:
Other Important Variables

• FHR Decelerations :
• Absence : Reassuring
• Mild non repetitive variable decelerations :
not significant
 NST : combining with other tests

• Post term pregnancy: USG for evaluation

of AFV
• IUGR: Umbilical Doppler
 NST Interpretation: Acute Vs
Chronic Hypoxia
• Acute Hypoxia : Abruptio placentae Marked
fetal bradycardia
• Chronic Hypoxia : IUGR Slower interruption
of oxygen supply to fetus fetal adaptation for
hypoxic state
1. baseline FHR: maintained
2. loss of beat to beat variability
3. diminished accelerations
4. late decelerations
 NST: With VAS Test

• Use of artificial larynx which produces a stimulus of

approx. 80-82 db over fetal head for 1-3 second to
stimulate FM.
• Startle response: fetus responds with sudden movement
followed by acceleration of FHR
• Decreases the time spent in performing NST ( prolonged
NST d/t episodes of fetal sleep)
• Maternal perception of fetal FM: also indicates fetal
wellbeing
• Safe: no evidence of hearing impairment in fetuses
exposed
 NST: With VAS Test

• Response of VAS is gestational age

dependent :
less than 24 wks : do not respond to VAS
24-27 wks : 30%
27-39 wks : 86%
>31 wks : 96%
• Only 20% NST are negative after VAS :
Reduced incidence of NRNST
 NST: With VAS Test

• VAS results may be affected by :

1) thickness of maternal abdominal wall
2) Amount of amniotic fluid

• Intrapartum non-reassuring FHR tracings

positive response to VAS non-acidotic
fetus
Contraction Stress Test : Rationale

Uterine Contractions

Marked or cessation of uteroplacental blood flow

Hypoxic Stress
Healthy fetus Compromised fetus

Tolerates without difficulty Cannot tolerate (decele)

 CST : Stimulation of uterine
contraction

• Spontaneous contraction + No need to

administer uterine stimulants
• Nipple stimulation : unpredictable
response
• Oxytocin
 CST : Endpoint

Late deceleration of FHR following uterine

contraction
• Earliest indicator of fetal compromise
• Appear before loss of variability
decreased FM
lack of tone
 CST : How to perform ?

Semifowler’s position
B.P. Monitoring
Tococardiographic instrument
Observe: FHR+ Uterine activity for 15-20 mins.
Oxytocin administration : not required
1) Adequate fetal activity 2) Adequate uterine activity
IV Oxytocin 0.5mIU/min: doubled every 15-20 min
( till 3-4 contractions lasting 40-60 sec in a 10 mins )
 CST : How to perform ?

Late decelerations before adequate contractions:

1) Stop oxytocin 2) Massage nipples with warm towel

Total Test Time : 1.5-2 hours

Amt. of Oxytocin for adequate contractions <16mU/min

Monitor FHR & uterine contractility : baseline

Persists: Inj. Terbutaline 250mg subcutaneously
 CST : Contraindications

• Placenta praevia
• Classical C.S.
• Extensive uterine surgery
• PROM
• Preterm labor
• High risk for preterm labour
 CST : False Positive Test

• Occur in 50% of cases

• Rate can be decreased by considering
other variables besides decelerations
(variability, accelerations )
• CST +ve + poor variability + absent
accelerations True Positive Test
• CST +ve + adequate variability +
accelerations False Positive Test
 CST: False Negative Rate

• O.4/1000
• Significantly better than NST
 CST : Present Status

• Infrequently used test for primary fetal

surveillance:
1) long duration of test
2) need for continuous supervision by trained
personnel
3) associated risks
4) contraindications
• Used to follow a non-reactive NST as adjunctive
test
 Biophysical Profile

• NST combined with ultrasonographic

evaluation of fetal breathing movements,
fetal tone, fetal body movements and AFV.
• Rationale : variables depend on the
integrity of CNS so affected with fetal
compromise due to hypoxia.
 Biophysical Profile : Interpretation

• FHR reactivity: 2 or more accelerations of atleast 15

bpm, lasting atleast 15 sec., in 10 mins. with/without FM
(reactive NST)
• Fetal breathing movements : 30 sec. of sustained BM
during 30 min. observation period.
• Fetal Movt. : 3 or more gross FM in 30 min. observation
period
• Fetal tone : 1 or more episode of limb motion from
position of flexion to extension & rapid return to flexion
• AFV : One Pocket of amniotic fluid at least 2 cm in two
perpendicular planes
 Biophysical Profile : Interpretetion

• Each of the five components is given a

score of two if normal or 0 if abnormal.
• A score of 10-8 ( without abnormal AFV) :
reassuring
• 8 ( with abnormal AFV) : further testing
• 6 : Equivocal : repeat/further testing
• 4 or less : fetal compromise
 Biophysical Profile: Merits and
Perils
• Advantage :
1) No contraindication
2) No risk to mother or fetus
• Disadvantages:
1) Time consuming
2) Require US training
3) Assessment of individual tests
4) Few alterations in the test result occur late in
process of fetal asphyxia
 Biophysical Profile

• False negative rate : 0.7/1000 ( better than

NST same as CST )
• False positive rate : 30 % ( better than
both NST & CST ).
 Biophysical Profile : Main Problem
Variable Appear Centre
• Five variables
Fetal tone 7-9 wks Brain
assessed in the test cortex
depend on activity FM -do- -do-
of different areas of Fetal 20-21 wks Ventral
fetal CNS which Breathing surface
become functional movt. of IV
at different ventricle
gestational age. FHR 28-30 wks Post.
activity Thalamus
& nu. In
upper
medulla
 Biophysical Profile : Main Problem

• Sensitivity of these centres to hypoxia differs

• Those which become functional earlier are
more resistant to changes in fetal
oxygenation Predictive value of each
fetal function to hypoxia is different

Evaluation of individual test rather than total

BPP score is a MUST
 Modified Biophysical Profile

• Vintzileos 1987 ; first proposed

modification of BPP
• Excellent test for primary fetal surveillance
• Combines :
1) NST with VAST(index of acute hypoxia)
2) AFV ( index of chronic hypoxia )
 Modified Biophysical Profile

• Advantages :
1. Excellent –ve and +ve predictive value
2. Easy to interpret
3. Clearly defined end points
4. Performed in average of 20 mins
Modified Biophysical Profile

NST + AFV
Normal
Weekly fetal surveillance with MBPP
NST + AFV
Both abnormal ( AFV, Non reactive NST)

>= 36 wks < 36 wks

Delivery Doppler Delivery
CST
Full BPP
 Modified Biophysical Profile

NST + AFV

AFV + normal NST

Search for indication of undiagnosed placental

insufficiency / ROM

Mg. according to final diagnosis

 Doppler Velocimetry

• Doppler study of umbilical, uterine, MCA at 23-

25 wks useful test for screening & selection
of women at high risk for PE & FGR
• Velocity : Systole>Diastole
• Diastole : Low peripheral vascular resistance
good amount of blood flow
• High resistance : minimal diastolic flow, most of
blood flows in systole
Umbilical + MCA artery Doppler

• Compliments other tests for fetal surveillance :

degree of fetal compromise precisely
• Determine need to deliver more precisely
• Follow-up test : when other tests give
ambiguous results / clinical condition of mother
& fetus is unstable
• Identify pts. at high risk for placental
insufficiency
• Evaluate presence & severity of fetal anemia
 Uterine Artery Doppler

Index of quality of utero-placental circulation

Reflect condition on maternal side

Pathophysiology of fetal hypoxia

Placental Insufficiency

Primary fetal adaptive response : Decrease in growth

Persistent placental insufficiency

Secondary fetal adaptive Response

• Decrease fetal movements
• Hemodynamic redistribution
• Increase heart rate
• Increase synthesis of RBCs
Pathophysiology of fetal hypoxia

Aggravating Placental insufficiency

Progressive Decompensation
• Respiratory & metabolic acidosis
• Impedance in fetal-placental circulation
• Renal insufficiency : AFV
• Myocardial compromise : absent or reversal of flow in
DV
• Late decelerations in FHR tracings
• Fetal death
Pathophysiology of fetal hypoxia

• No single test can identify these events of

pathophysiological changes d/t placental
insufficiency & fetal hypoxia
• Simultaneous use of biophysical and
hemodynamic parameters gives best
perinatal outcome in growth restricted
fetuses
 Umbilical Artery Doppler

• Index of resistance to flow in the fetal side of

placenta
• Sequence of fetal hemodynamic changes d/t
placental insufficiency
• UA waveforms can be analyzed as
1) Systolic/Diastolic or S/D ratio (USA)
2) Pulsality index (PI): (Sys-Dias)/Mean ( Europe)
3) Resistance index (RI): Sys-Dias/Sys
 Umbilical Artery Doppler:
Prerequisites to Obtain Waveform

• Best Site: Middle of the cord in one of the loops

floating in the amniotic fluid (sites closer to fetal
insertion of umbilical cord : show high
resistance)
• Best Time: 1) fetus is not moving
2) respiratory movements are absent
• At least 4 measurements / waveforms should be
taken & their S/D ratios are averaged
Umbilical Artery Doppler: Changes
in the UA waveforms + Venous
system
• Progressive fetal compromise secondary to
increasing placental insufficiency:
 UA resistance without centralization of flow

 UA resistance with centralization of flow

 Absent umbilical A. diastolic flow (AUADF)

 Reversed UA diastolic flow (RUADF)

 Alteration in the venous circulation

Umbilical Artery Doppler: S/D Ratio
Changes
No. of A. in the tertiary stem villi

Elevated S/D ratio in UA( without centralization)

Placental capacity to provide glucose, oxygen, nutrients to fetus

Progression of placental lesion & fetal demands : compensatory

haemodynamic response
Centralization of flow ( doppler assessment of MCA)

Further aggravation of placental insufficiency

More severe changes in the UA waveforms
Umbilical Artery Doppler: Abnormal
waveforms in IUGR
• Associated with :
 oligo hydramnios
 abnormal NST
 LBW
 lowered average Dx to delivery interval
 lower average fetal gestational age
 higher incidence admissions to fetal NICU
 higher risk of necrotizing enterocolitis
 Umbilical Artery Doppler:
Interpretation
• Increased UA resistance : progressive S/D
Ratio:
 First sign of fetal compromise
 Normal MCA S/D Ratio ( > S/D ratio of UA) : less
worrisome closer & frequent fetal surveillance
to detect further deterioration
 Lower MCA S/D Ratio (centralization): Brain
sparing effect Immediate delivery OR only
if very much required short continuation with
very close surveillance
 Umbilical Artery Doppler:
Interpretation

• Absent U.A. Diastolic flow :

 Placental Vas. Resistance UA
blood flow only in systole Fetal
oxygen supply Mild metabolic acidosis
 Serious consideration to delivery
 Expectancy : only if very necessary with
daily NSTs + frequent doppler
examinations
 Umbilical Artery Doppler:
Interpretation

• Reversed UA Diastolic Flow :

 Ominous sign

 Considerable increase in resistance

 Fetus is acidotic

 Need delivery

 High risk of death and neonatal morbidity

 Ductus Venosus Doppler
• Index of right/venous side of circulation
• DV waveforms :
 Maximum velocity: ventricular systole

 Minimum velocity : right atrial contraction

 Normal waveform: uninterrupted forward flow

during systole & diastole of cardiac cycle
• Final stages of fetal compromise Placental
insuff. Oxygen deficit + acidemia
Affects cardiac function Rt. Ventricular
preload (CHF) Interrupted forward flow
(absent / reversed flow during atrial contraction )
Ominous sign
• Poor fetal health & neonatal outcome
Uterine Artery Doppler: Rationale

Internal Iliac Artery

Uterine Artery
Arcuate Artery
Radial Artery
Basal Artery
Spiral Artery
 Uterine Artery Doppler: Rationale

Trophoblastic invasion of spiral arteries

• Mimp physiological adaptation
• Increases blood flow 10 folds
• Fulfills nutritional & respiratory needs of feto-
placental unit
• Diameter increases: 15-29um to 300-500um
• High resistance vascular system low
resistance to maintain blood flow to intervillous
space after 10-12wks
 Uterine Artery Doppler: Rationale

Abnormalities of Trophoblastic invasion

• Preeclampsia
• IUGR
• Preterm labour
• PROM
• Fetal death
 Uterine Artery Doppler

• Changes in vascular resistance in the ipsilateral

uterine artery
1) More marked
2) Appear before artery on contralateral side (20
wks Vs 26 wks)
• Doppler study of uterine artery
1. At 24 wks
2. Transabdominal US usually
3. Transvaginal US in obese
 Uterine Artery Doppler

• Indices –
1. SD ratio >3 after 30 wks
2. RI >0.56
3. PI>1.56
4. Protodiastolic notch in the ipsilateral A. at 20
wks & contralateral A. after 26 wks .
• Protodiastolic notch: at beginning of diastole
1. Index of increased impedance to flow
2. Simultaneous brief decrease in velocity
 Uterine Artery Doppler
• Use of uterine A. doppler as screening test:
1. Abnormal placentation occurs long before the
clinical appearance of obstetric complication
2. Abnormal uterine doppler after 24 wks of
gestation are associated with development of
PE & FGR
3. PPV is poor –used in general obst . population
is limited
4. In pregnancy with high risk factor for PE, FGR
& abnormal pregnancy outcome –diagnostic
value increases
 Uterine Artery Doppler

5. Abnormal doppler of uterine A .+ clinically high

risk pregnancy  closer prenatal follow up
6.Normal uterine doppler in high risk pregnancy 
reassuring ,less frequent fetal surveillance
• Predictive value of uterine A doppler can be
increased by combing it with
1. Maternal serum inhibin A & activine A (PE)
2. Maternal plasma protein 13 in 1st trimester
• Depth of protodiastolic notch severity of
pathology of placentation in PE or FGR
 Uterine Artery Doppler

• In pts. with FGR: normal UA doppler with

abnormal uterine A doppler  pathologic
process occurring in maternal site of
placenta
 FETAL BLOOD SAMPLING
(PUBS)
• Cordocentesis : Daffos 1983
• Easily performed at after 24 wks of gestation
• Site : any site on umbilical cord preferably
placental insertion site
• Requires : high resolution US,20-22G
needle , sector / linear scanning , free hand / US
guidance technique
• Risk : 1. Bleeding from puncture site
2. severe fetal brady. (vagal reflux)
3 . Fetal death 1:100 cases
• Efficiency of operator
 FETAL BLOOD SAMPLING
(PUBS)
• Indication :
1. Rapid karyotype in fetuses with structural abnormality
discovered during US exam.
2. Fetal hemolytic disease
3. Suspected viral infection
4. Non immunologic hydrops fetalis
5. Suspected fetal thrombocytopenia
6. Dx of twin twin transfusion syndrome
7. Suspected fetal hemoglobinopathy
8. FHR cannot be safely interpreted
 Indications for antepartum
monitoring

• Any fetus at increased risk of demise

• All indications are relative due to lack of
definitive evidence that mortality rates
improved
 Maternal and Fetal Indications

• APLS • Hypertensive disorders

• Hyperthyroidism • Decreased fetal movement
• Hemoglobinopathies • Oligo/polyhydramnios
• Cyanotic heart disease • IUGR
• SLE • Postterm pregnancy
• Chronic renal dz • Isoimmunization
• DM 1 and 2 – Moderate to severe
• Previous fetal demise
– Unexplained or recurrent risk
• Multiple gestation with growth
discordancy
• APH
 What to do if test is abnormal?

• True false-positive test results not known

– Test introduced without rigorous evaluation of utility
• Abnormal result in context of clinical situation
– Did maternal condition change?
– Abnormal test usually followed by other test
• 90% of NRNSTs followed by negative CST
– If NRNST followed by positive CST, delivery
warranted in morphologically normal fetus
 Which test to use?

• Most evidence points to use of NST as first line

test
• Imperative to remember that it should not be
used a sole test
• Other tests should be used in situation of
nonreassuring testing such as BPP or CST
• NST can be used in conjunction with Doppler
studies in IUGR
 When to start?

• Risk of iatrogenic prematurity and false-positive

results
– Up to 60% of neonates with nonreassuring testing
had no short- or long-term compromise
• Large clinical studies show 32-34 weeks to be
most beneficial
• May start earlier in certain high-risk situations
– poorly controlled diabetes, R/F with IUGR
• AJOG 1996;174:812-817
• AJOG 1993;168:1820-1826
• AJOG 1991;164:1563-1570
 How frequently?

• Interval should be driven by the requirements for

the test
• Should be no more than 7 days
• May be daily in some critical / unstable situations
– Severe preeclampsia
• Reduction in IUFDs with twice-weekly testing
– 6.1/1.000 to 1.9/1,000
to be cont…