Antenatal Assessment of Fetal Well

Being

Dr.Abdulkarim Ahmed Mohamud

OBS/GYN Specialist @ Somali
Syrian hospital
MBChB (UST), MMed (UoN)
important causes of deaths at antepartum period

 (i) Chronic fetal hypoxia (IUGR).

 (ii) Maternal complications, e.g. diabetes,
hypertension, infection.
 (iii) Fetal congenital malformation and
 (iv) Unexplained cause.
Aims of antenatal fetal monitoring
 • To ensure satisfactory growth and well being of
the fetus throughout pregnancy.
 • To screen out the high risk factors that affect the
growth of the fetus.
Common indications for antepartum fetal monitoring

 • Pregnancy with obstetric complications:

 IUGR,
 Multiple pregnancy,
 Polyhydramnios or Oligohydramnios,
 Rhesus alloimmunization.
 • Pregnancy with medical complications:
 Diabetes mellitus,
 Hypertension,
 Epilepsy,
 Renal or Cardiac disease,
 Infection (Tuberculosis),
 SLE.
 • Others:
 Advanced maternal age (> 35 years),
 previous still birth or recurrent abortion,
 previous birth of a baby with structural
(anencephaly, spina bifida) or chromosomal
(autosomal trisomy) abnormalities.
 • Routine antenatal testing.
Clinical Evaluation Of Fetal Well Being At
Antenatal Clinic
 At First Visit
 History taking
 Examination : size of the uterus
 Ultrasonography: gestational age
 At Subsequent Visits
 At every antenatal visit, the following clinical
parameters are taken into account for assessment
of satisfactory progress of gestation.
I. Maternal weight gain
II. Blood pressure
III. size of the uterus and height of the fundus
IV. excess liquor AND scanty liquor in the last trimester.
V. girth of the abdomen in the last trimester
 SPECIAL INVESTIGATIONS
 Antepartum fetal deaths:
 30% due to asphyxia (IUGR, post dates),
 30% due to maternal complications (pre-eclampsia,
placental abruption, diabetes mellitus),
 15% to congenital malformations and chromosomal
abnormalities and
 5% to infection.
 20% of stillbirths have no obvious cause.
 50% of first trimester spontaneous abortions and about
5% of stillborn infants have chromosomal abnormalities.
 EARLY PREGNANCY
 • Biochemical
 • Biophysical
 • Cytogenetic
BIOCHEMICAL
 Maternal serum alpha fetoprotein (MSAFP):
 Is onco-fetal protein (Molecular weight 70,000).
 It is produced by yolk sac and fetal liver.
 Test is done between 15–20 weeks.
 Highest level in fetal serum and amniotic fluid is
reached around 13 weeks and thereafter it
decreases.
 Maternal serum level reaches a peak around 32
weeks.
 MSAFP
 level is elevated in:
 (a) wrong gestational age
 (b) open neural tube defects (NTDs)
 (c) multiple pregnancy, Rh isoimmunization
 (d) IUFD
 (e) anterior abdominal wall defects
 (f) renal anomalies.
 Low levels are found in:
 trisomies (Down’s syndrome), gestational trophoblastic
disease.
 Triple test:
 MSAFP, hCG and UE3 (unconjugated estriol).
 It is performed at 15–18 weeks.
 It is used for detection of Down’s syndrome.
 level of MSAFP and UE3 tend to be low while that of
hCG is high.
 Acetylcholine esterase: (AChE)
 Amniotic fluid AChE level is elevated in most cases
of open neural tube defects(NTD).
 It has got better diagnostic value than AFP.
 Inhibin A
 is a dimeric glycoprotein.
 It is produced by the corpus luteum and the
placenta.
 Serum level of inhibin A is raised in women carrying
a fetus with Down’s syndrome.
 Amniotic fluid AFP
 The normal AFP concentration in liquor amnii at the
16th week is about 20 mg/liter.
 level is high when the fetus suffers from open neural
tube defects.
 This is also confirmed by ultrasound scanning.
 Amniotic fluid level of 17 hydroxy progesterone
 is raised in congenital adrenal hyperplasia.
 First trimester screening:
 ↑ hCG, ↓ MSAFP, ↓ PAPP can detect trisomy 21 in
85% with a false positive rate of 5%.
 When nasal bone detection is combined together,
the detection rates rise to 97%.
 Second trimester screening (15–18 weeks):
 Triple test (↓ MSAFP, ↓ UE3, ↑ Total hCG) can
detect trisomy 21 in 70%
 quadruple test (↓ MSAFP, ↓ UE3, ↑ Total hCG, ↑
Inhibin A) can detect trisomy 21 in 80%.
BIOPHYSICAL:
 Ultrasonographic (10–14 weeks) :
 Crown-Rump Length (CRL) smaller than the gestational
age is associated with the risk of chromosomal
anomalies (trisomy or triploidy).
 Increased nuchal translucency (NT) is associated with
many chromosomal abnormalities (trisomy, monosomy,
triploidy). Detection rate is about 70–80% with a false
positive rate of 5–6%.
 Absence of nasal bone (NB) on USG at 10–12 weeks
is associated with fetal Down’s syndrome. When NB and
NT were combined detection rate of trisomy 21 was 92%
with a false positive rate of 3.5%.
Cytogenetic analysis
 The desquamated fetal cells in the amniotic fluid,
obtained by amniocentesis (between 14 and 16
weeks)
 trophoblast cells from CVS (between 10–12 weeks)
 fetal blood cells obtained by cordocentesis (from 18
weeks gestation.)
 These cells are cultured, G banded and examined
to make a diagnosis of chromosomal anomalies,
e.g. trisomy 21 (Down’s syndrome), monosomy X
(Turner’s syndrome) and others.
 • DNA analysis:
 Single gene disorders (cystic fibrosis, Tay-Sachs
disease) can be diagnosed using specific DNA
probes.
 DNA amplification is done by PCR.
 The specific chromosomal region containing the
mutated gene can be identified.
 ANTEPARTUM FETAL SURVEILLANCE
(LATE PREGNANCY)

 OBJECTIVES ARE:
 (1) prevention of fetal death
 (2) avoidance of unnecessary interventions.
 METHODS:
 • Clinical
 • Biochemical
 • Biophysical
CLINICAL
 The clinical assessment of fetal growth.
BIOCHEMICAL
 Pulmonary maturity:
 Confirmation of lung maturation reduces RDS in
the newborn that are delivered preterm (< 37
weeks).
 RDS is caused by the deficiency of pulmonary
surfactant , which is synthesized by the type II
alveolar cells.
 Surfactant is packaged in lamellar bodies →
discharged in the lung alveoli → carried in the
pulmonary fluid → carried into the amniotic fluid.
Assessment of fetal pulmonary maturity
1. lecithin/sphingomyelin (L/S) ratio> 2
2. shake test or bubble test (clement’s): 96% ethanol, shaken for 15
seconds complete ring of bubbles at the meniscus
3. foam stability index (FSI): >47
4. presence of phosphatidyl glycerol (PG) .
5. saturated phosphatidyl choline :> 500 ng/ml
6. fluorescence polarization: ratio of surfactant to albumin 55 mg per
gram
7. amniotic fluid optical density at 650 mμ greater than 0.15
8. Lamellar body count > 30,000/μL
9. Orange colored cells: centrifuged amniotic fluid are stained with 0.1%
Nile blue sulfate. > 50%
10. Amniotic fluid turbidity: At term it is turbid due to vernix
 1. Estimation of pulmonary surfactant by
Lecithin/Sphingomyelin (L/S) ratio.
 Amniotic fluid L/S ratio
 at 31–32 weeks is 1
 at 35 weeks L/S ratio is 2
 L/S ratio > 2 indicates pulmonary maturity.
 2. Shake test or Bubble test (Clement’s):
 Amniotic fluid are mixed with 96% ethanol, shaken
for 15 seconds and inspected after 15 minutes for
the presence of a complete ring of bubbles at the
meniscus.
 If it is present, the test is positive and indicates
maturity of the fetal lungs.
 3. Foam Stability Index (FSI):
 is based on surfactant detection by shake test.
 FSI is calculated by utilizing serial dilutions of
amniotic fluid to quantitate the amount of surfactant
present.
 FSI >47 virtually excludes the risk of RDS.
 4. Presence of phosphatidyl glycerol (PG)
 in amniotic fluid reliably indicates lung maturation.
 PG is tested by thin layer chromatography similar to
L: S measurement.
 5. Saturated phosphatidyl choline :
 > 500 ng/mL indicates pulmonary maturity.
 6. Fluorescence polarization:
 This test utilizes polarized light to quantitate
surfactant in the amniotic fluid.
 The ratio of surfactant to albumin is measured by an
automatic analyzer.
 Presence of 55 mg of surfactant per gram of
albumin indicates fetal lung maturity.
 7. Amniotic fluid optical density at 650 mμ
 greater than 0.15 indicates lung maturity.
 8. Lamellar body
 is the storage form of surfactant in the amniotic fluid.
 A lamellar body count > 30,000/μL indicates
pulmonary maturity.
 9. Orange colored cells:
 desquamated fetal cells obtained from the
centrifuged amniotic fluid are stained with 0.1% Nile
blue sulfate.
 Presence of orange coloured cells > 50% suggests
pulmonary maturity.
 10. Amniotic fluid turbidity:
 During first and second trimesters, amniotic fluid is
yellow and clear.
 At term it is turbid due to vernix.
BIOPHYSICAL
 Biophysical profile is a screening test for utero-
placental insufficiency.
 The fetal biophysical activities are initiated,
modulated and regulated through fetal nervous
system.
 The fetal CNS is very much sensitive to diminished
oxygenation.
 Hypoxia → metabolic acidosis → CNS depression
→ changes in fetal biophysical activity.
 Fetal movement count:
 Any of the two methods can be applied:
 • Cardif ‘count 10’ formula
 • Daily fetal movement count (DFMC)
 • Cardif ‘count 10’ formula:
 She is instructed to report the physician if:
 (i) less than 10 movements occur during 12 hours
on 2 successive days or
 (ii) no movement is perceived even after 12 hours
in a single day.
 • Daily fetal movement count (DFMC):
 Three counts each of one hour duration (morning,
noon and evening).
 The total counts multiplied by four gives (12 hour)
DFMC.
 less than 10 in 12 hours (or less than 3 in each
hour), it indicates fetal compromise.
Fetal Biophysical Profile (BPP):
 Modified Biophysical Profile:
 Consists of NST and AFI.
 Abnormal (non-reassuring) when:
 NST is non-reactive and/or
 AFI is < 5.
 Fetal Cardiotocography (CTG):
 A normal tracing after 32 weeks, would show:
 base line heart rate of 110–150 bpm with an
 Amplitude of base line variability 5–25 bpm.
 No deceleration or there may be early deceleration
of very short duration.
 ≥2 accelerations during a 20-minute period.
 Umbilical artery flow velocity waveform:
(A) Normal;
(B) Abnormal:
(i)Reduced end-diastolic flow
(ii)Absent end-diastolic flow
(iii)Reversed end-diastolic flow
Thank you