ASSESSMENT OF FETAL WELL

BEING
Maham Khan
2018/046
AIMS
 The primary objective of the assessment is to avoid fetal
death.
 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.
 To detect congenital abnormalities and inborn metabolic
disorders during early pregnancy.
Indications
 Diabetes
 Isoimmunization
 Hypertensive disorders
 Oligohydramnios or polyhydramnios
 Fetal growth restriction
 Prior fetal demise
 Twin pregnancy
 Preterm premature rupture of Postterm pregnancy
 membranes Decreased fetal activity
 Other (Nonimmune hydrops, Systemic lupus erythematosus
 maternal cyanotic heart disease, Antiphospholipid syndrome
 poorly controlled maternal Sickle cell disease hyperthyroidism, and
maternal vascular diseases)
Main techniques for fetal assessment

 The nonstress test (NST),

 Biophysical profile,
 Modified biophysical profile,
 Contraction stress test (CST)
 Fetal movement count.
 Assessment of amniotic fluid volume and Doppler
velocimetry
Fetal movement count
 Objective maternal assessment of fetal movements is
based onevidence that fetal movement decreases in
response to hypoxemia.
 Women with decreased fetal movement should undergo
furtherfetal assessment,
 6 or more movements in 2 hours.
 Fetal movement increases throughout day, with peak
activity late at night.
 The frequency of fetal movement in normal pregnancy is
probably constant throughout the third trimester
Ultrasound
 Ultrasound is the principal imaging modality used in
obstetrics
 Ultrasound is used to date pregnancies as early as 6 weeks
to monitor growth of the fetus and to identify congenital
abnormalities.
 Antenatal tests of fetal wellbeing are now principally
based on ultrasound techniques and are designed to
identify fetuses that are in the early or late stages of fetal
hypoxia.
 Determine how advanced the pregnancy is.
 Detect congenital anomalies and problems.
 Localize the placenta.
 Assess fetal status – heartbeat, breathing movements.
 Diagnose cardiac problems.
 Detect fetal presentation, number of fetus .
Viability of the fetus
 The gestational sac can be visualized from as early as 4–5
weeks’ gestation and the yolk sac at about 5 weeks .
 The embryo can be observed and measured at 5–6 weeks’
gestation.
 Beating of the fetal heart can be visualized by about 6 weeks.
 In a missed miscarriage, for example, the fetus can be
identified, but with an absent fetal heartbeat.
 In a blighted ovum (or anembryonic pregnancy), there is a
gestation sac present but it is empty because the fetus has
failed to develop.
 An ectopic pregnancy is suspected if, in the presence of a
positive pregnancy test, theres no gestational sac.
 Gestational age
 Up to approximately 20 weeks’ gestation we
can measure the for measurements of fetal
length, head size and long bone length.

 The crown–rump length (CRL) is used up to

13 weeks + 6 days

 the head circumference (HC) from 14 to 20

weeks’ gestation.

 In the latter part of pregnancy, measuring

fetal abdominal circumference (AC) and HC
will allow assessment of the size and growth
of the fetus and will assist in the diagnosis
and management of fetal growth restriction
(FGR).
Diagnosis of fetal anamolies

 Major fetal structural abnormalities occur in 2–3% of

pregnancies and many can be diagnosed by an ultrasound
scan at around or before 20 weeks’ gestation.

 Limitations maybe, poor visualization or late

development of anamoly.
Placenta localization
 Ultrasonography and transvaginal approach has become
indispensible in the localization of the site of the placenta.
 At the 20 weeks scan, a low-lying placenta can be
identified.
(At this stage, the lower uterine segment has not yet formed
and most low-lying placentas will appear to ‘migrate’
upwards as the lower segment stretches in the late second
and third trimesters)
 About 15–20% of women have a low-lying placenta at 20
weeks, and only 10% of this group will eventually be
shown to have a placenta praevia
Amniotic fluid
 Ultrasound can be used to identify both increased and
decreased amniotic fluid volumes.
 Congenital abnormalities that either structurally or functionally
impair the fetus’s ability to swallow, for example oesophageal
atresia or anencephaly, will result in an increase in amniotic
fluid (polyhydroamnios).
 Congenital abnormalities that result in a failure of urine
production or passage, for example renal agenesis , FGR and
posterior urethral valves, will result in reduced or absent
amniotic fluid.
✓ Normal – depth >2 cm and <8 cm
Oligohydramnios – depth <2 cm
✓ Polyhydramnios – depth 28 cm
Cardiotocograph
 The cardiotocograph (CTG) is a continuous tracing of the fetal
heart rate with an assessment of uterine activity.
 Two external transducers are placed on the mother’s abdomen
One transducer is a pressure-sensitive contraction
tocodynometer (stretch gauge) that measures contraction.
 The second transducer uses ultrasound and the Doppler effect
to detect motion of the fetal heart, and measures the interval
between successive beats
 Recordings are then made for at least 30 minutes with the
output from the CTG machine producing two ‘lines’ traced
onto a running piece of paper, one a tracing of fetal heart rate
and a second a tracing of uterine activity.
 Results
 Reactive -- two
accelerations of
15 BPM lasting
15 seconds,
associated with
fetal movement.
This is an
indication of fetal
well-being
 Nonreactive --
no accelerations
of FHR.
Indication of
need for further
assessment
Reactive CTG
Non reactive CTG
Biophysical profile
Comprehensive assessment of five
Biophysical variables:
 Fetal breathing movement
 Fetal movements of body or limbs
 Fetal tone (extension and flexion of extremities)
 Amniotic fluid volume – visualized as pockets around the
fetus
 Reactive FHR with activitity (reactive NST)
Amniocentesis
 An invasive procedure
 Requires a consent form to be signed
 Performed about 14 - 16 weeks gestation
 Patient must be informed of possible complications
 Trauma
 Infection
 Hemorrhage
Indications
 fetal chromosomal anomalies after other tests such as
ultrasound or biophysical markers have determined a
significant likelihood that the fetus will be affected with a
chromosomal problem.
 fetal lung maturity (detects sphingomylein levels)
 evaluating alloimmunization.
 Amniocentesis can also be used to obtain samples to rule
out chorioamnionitis.
Tests
 Triple Test
 AFP
 hCG
 Unconjugated estriol
 Genetic studies
 Most commonly used to diagnose Down syndrome.
 Fetal Lung Maturity
 L/S ratio – lecithin-sphingomyelin ratio
 Lecithin should become 2 - 3 times greater than sphingomyelin by
about 35 weeks
 Fetal maturity is attained when the L/S ratio is 2 : 1
Doppler velocimetry

 Non invaisve

 Measures the blood flow in fetal and maternal vessels and

provide the information about uteroplacental blood and
fetal respose to physiological changes
 Uterine artery
A number of investigators have explored the use
 of uterine artery Doppler for third trimester fetal assessment
among women with complicated pregnancies, but its role in
these settings has not been clearly defined

Middle cerebral artery

Doppler assessment ofthe fetal middle cerebral artery-peak
systolic velocity is the best tool for monitoring for fetal anemia
in at-risk pregnancies

 Umblical artery
 provide information on placental resistance to blood flow
and hence indirectly placenta ‘health’ and function
Alpha feroprotein Chorionic villi sampling

Measurement of a Removal of small tissue

protein produced by the specimen from the
yolk sac and fetal liver fetal portion of the placenta

Elevated levels of AFP Tissue obtained about 8 - 10

may be indicative of weeks gestation
open neural tube defects
because the AFP leaks Chromosomal studies
out of the fetal performed
circulation into the
amniotic fluid Advantage – can be done
earlier than an amniocentesis
to detect problems.
Disadvantage – spontaneous
abortion