ANTEPARTUM FETAL

SURVEILLANCE
GOAL:
To reduce the rate of still birth by identifying the fetus that will benefit from early
intervention such as in utero resuscitation or delivery and thereby preventing fetal
death or neurologic injury

Physiological basis:
 Fetus responds to hypoxemia with a detectable sequence of biophysical
changes

Patient selection:
 Risk of still birth rate is >0.8/1000 population
TECHNIQUES :

 FETAL MOVEMENT COUNT

 CONTRACTION STRESS TEST
 NON STRESS TEST
 BIOPHYSICAL PROFILE
 MODIFIED BIOPHYSICAL PROFILE
TEST FALSE NEGATIVE RATE FALSE POSITIVE RATE
(%) (%)
CONTRACTION STRESS 0.04 35-65
TEST
NON STRESS TEST 0.2-0.8 55-90

Biophysical profile 0.07-0.08 40-50

Modified biophysical profile 0.08 60

 FETA MOVEMENT COUNT :
 Based on the evidence that fetal movement count decreases in response to
hypoxemia
 Maternal fetal perception begins at around 16 to 20 weeks,occurs earlier in
parous women
 Frequency increases from morning to night ,peak activity at night 9P:M to
10A:M
 Maternal hypoglycemia is associated with increased fetal movement count
 10 FETAL MOVEMENTS IN 2 hours
 Factors that influence evaluation –
 Maternal activity,parity,obesity,medications ,psychological factors
Contraction Stress test:

 Fetus with inadequate placental respiratory reserve would demonstrate recurrent late
decelerations in response to hypoxia ,mediated by vagal response

 Test:
 Patient is in semi fowler position , slight left tilt to avoid supine hypotensiom
 Continuous external fetal heart rate and uterine contaction monitoring is recorded
 Maternal blood pressure is determined every 5 to 10 min
 CST requires uterine contractions that last for about 40 to 60 seconds with a frequency of
3 in 10 min
INTERPRETATION:
 NEGATIVE : No late or significant variable decelerations

 POSITIVE : Late decelerations with atleast 50% of contractions

 SUSPICIOUS : Intermitent late or variable decelerations

 HYPERSTIMULATION : Decelerations with contractions longer than 90

seconds duration or a greater than 2 min frequency

 UNSATISFACTORY : Fewer than three contractions per 10 min or an

uninterpretable tracing
 Negative CST has been consistently associated with good fetal outcome

 Perinatal death within 1 week of a negative CST to be less than 1 per 1000

 Cannot predict acute fetal compromise

 Negative and reactive CST – repeat after 1 week

 Negtaive and non reactive – repeat in 24 hrs

 Postive CST is associated with increased incidence of IUD, MSL,IUGR,low 5 min apgar
scores , late decelerations in labour

 Peinatal mortality rate after positive CST is from 7%to 15%

 High incidence of false positive CST
 NON STRESS TEST :
 Late gestation healthy fetus exhibits average of 34 accelerations in each hour

 Acclerations require intact neurologic coupling between the fetal CNS and the fetal heart

 REACTIVE NST:
 >32 wks -2 accelerations of the fetal heart rate each with a peak amplitude of 15 beats /min and to
tal duration of 15 sec observed in 20 min of monitoring
 < 32 wks – 2 accelerations 10 beats /min amplitude and 10 sec in 20 min
 NST is non reactive in 50 % of fetuses between 24 to 28 wks and 15% of fetuses between 28 t 32
wks
FETAL BIOPHYSICAL SCORE :
5 VARIABLES:

 Fetal breathing movements

 Gross body movements

 Fetal tone

 Reactive fetal heart rate

 Amniotic fluid volume

Fetal biophysical activities that are present earliest in fetal development are the last to
disappear with fetal hypoxia

TONE CORTEX 7.5WKS -8.5WKS

FETAL MOVEMENT CORTEX 9 WKS

BREATHING VENTRAL SURFACE OF 20WKS -21WKS

MOVEMENTS THE FOURTH VENTRICLE

FETAL HEART RATE HYPOTHALAMUS AND LATE 2ND TRIMESTER –

MEDULLA EARLY 3RD TRIMESTER
 BPP correlates well with fetal acid base status
 Antenatal corticosteroids administration may have an effect on the BPP , decreasing the score
upto 48 hrs
 Most commonly affected variable are FBM and NST

Modified BPP:
 NST +AFI
 NST- indicator of persent fetal condition ,AFI is long term status
 Mbpp has a false positive rate comparable to that of the NST but higher than that of
CST and full BPP
 Criteria of BPP:
VARIABL NORMAL ABNORMAL
E

FBM >\= 1 episode of >/=30s duration in 30 min Absent or no episode of>/= 30s in 30
min

GBM >\= 3 discrete body/limb movements in 30 min Upto two episodes of movements in 30
min

TONE >\=1 episode of active extension with returned flexion of fetal Slow extension with return – partial
limb /trunk,with opening and closing of the hand flexion movement of limb in full
extension \absent fetal movement
NST >\= 2 episodes of accelerations of>\= 15beats /min and 15 sec < 2 accelerations /acc < 15beats /min in
duration in 20 min 20 min

AFI At leats one pocket >\= 2cm in two perpendicular planes No amniotic fluid pockets or a pocket
<2cm in two perpendicular planes
 MANAGEMENT BASED ON BPP:
SCORE INTERPRETATION MANAGEMENT

10 Normal/low risk Weekly to twice weekly

8 Normal /low risk Weekly to twice weekly

6 Suspect chronic asphyxia
4 Suspect chronic asphyxia
>\=36-37 wks or <36wks with fetal pulmonary maturity +ve consider
delivery
<36wks /fetal pulmonary maturity is –ve repeat BPP in 4-6 hrs ,deliver if
oligohydramnios is present
>\= 36 wks deliver
<32wks repeat score

0-2 Strongly suspect chronic asphyxia Extend testing time -120 min , if persistent score is </=4 deliver regardless
of gestational age
Factor Suggested GA to begin AFS Suggested frequency of AFS
FETAL GROWTH
RESTRICTION
Umblical artery doppler

normal or with elevated impedence At diagnosis Once or twice weekly

to flow in umblical artery with
normal AFI ,diastolic flow

AEDF/oligohydramnios /maternal At diagnosis Twice weekly consider inpatient

comorbidities pre eclampsia /chronic management
hypertension

REDF At diagnosis Inpatient management

CHRONIC HYPERTENSION
Controlled with medication 32 WKS WEEKLY

uncontrolled At diagnosis individualised

Gestational hypertension/pre
eclampsia

Without severe features At diagnosis Twice weekly

With severe features At diagnosis daily

  DIABETES

Gestational controlled with 32 wks Once or twice weekly

medications

Gestational , poorly controlled 32wks Twice weekly

Pregestational 32 wks Twice weekly

Prepregnancy BMI

35-39.9 kg/m2 37wks weekly

>\= 40 kg/m2 34wks weekly

Renal disease 32 weeks Once or twice weekly

IVF 36 weeks weekly

cholestasis At diagnosis Once /twice weekly

Late term >41 weeks Once /twice weekly

Chronic placental abruption At diagnosis weekly

Velamentous cord insertion 36 wks weekly

Single umblical artery 36wks weekly

Isolated oligohydraminos At diagnosis Once /twice weekly

polyhydraminos 32-34 weeks Once /twice weekly

Previous h/o still birth at or after 32 32 wks Once or twice weekly
weeks

Stillbirth before 32 weeks individualised individualised

Previous FGR requiring preterm 32 wks weekly

delivery

Previous pre eclampsia requiring 32 wks weekly

preterm delivery

Substance abuse 5 or more drinks per 36 wks weekly

week

Decreased fetal movement At diagnosis Once , repeat if DFM reoccurs

Uncomplicated DADC twins 36 wks weekly

Uncomplicated MCDA twins 32 wks weekly

Heart disease 32 wks Once /twice weekly

SLE uncomplicated 32 wks weekly

SLE complicated At diagnosis individualised

Antiphospholipid sundrome 32 wks Twice weekly