SURVEILLANCE
USTMED ’07 Sec C - AsM - Because of increased maternal
carboxyhemoglobin levels or direct effect of
nicotine on Fetal CNS
Antepartum Fetal Surveillance
Definition - All methods to monitor fetal well being before labor
Electronic Fetal Heart Rate Monitoring
Administered :
1. age of gestation when fetal survival possible
2. When neuro developmental center is already operative
- Method:
Most attractive and convenient “ count to 10”
Performed at any convenient time
Patient Left lateral , concentrate on fetal activity Reactive Non-reactive
Evening hours, recent meal not necessary - Reactive Test - good fetal well being for 1 week or
Father help in charting promote family more in > 99% of cases.
attachment and compliance
- Non- Reactive Test – poor fetal outcome (perinatal
- Fetal Kick Count Chart death, Low 5 min. AS, late decels.) in < 20 % cases
Contact physician if >1 hr to feel 10 movements - Uncertain Reactivity- repeat NST, back-up BPS, CST
depending on clinical condition or OB judgement.
- Limitations of Fetal Movement Counting
1. Patient Comprehension and Convenience - Limitations of NST
Clear instructions mandatory 1. Fetal Sleep State
- Fetal sleep state affects fetal
Educational attainment and socioeconomic
cardioregulatory center, periodic variation in
background
variability
Problem of compliance before advent of “
Count to 10 method” - Periods of quiet sleep last for 1 hr. extend
2. Failure to anticipate certain stillbirths: observation time to eliminate possibility of
No technique can anticipate stillbirths fetal sleep state
- OFFSET LIMITATION
When FMC reassuring , still births may be due
to acute hypoxic changes (abruptio placenta, “10-20-40” rule
umbilical cord compression) - Extension to 90 min. improve false (+) rate
3. Failure to detect growth abnormalities: - Fetal inactivity may be prolonged up to 1 hr.
- Diminished activity only in the most severe
cases of IUGR < 5h percentile 2. DRUGS
( Matthew,1975) - Increase FHR
Mechanism Example
4. Failure to detect malformations:
B-adrenergic Ritodrine
- Most fetuses w/ congenital anomalies show
stimulation Terbulatline
normal fetal movement patterns
Isoxuprine
- Fetuses w/CNS anomalies (hydrocephalus) or Increase Metabolic rate Caffeine, Thyroxine
restriction of the LE (congenital hip CNS stimulants Cocaine, Ketamine
dysplasia) ↓ FM (Rayburn, 1985) Vagal Blockade Atropine
5. Failure to distinguish bet multiple pregnancies: Paracatechol Stimulants Ephedrine
A-adrenergic blockade Phentolamine
- Technique cannot distinguish between twins
on daily basis. - Decrease FHR
- Mother cannot determine which of the Mechanisms Example
fetuses are less active. Vagal Stimulation/SA Digoxin
6. Drugs Myocardial depressants Lidocaine
B-sympathetic blockade Propanolol
- Depressant drugs: barbiturates,
CNS depressants General anesthetics
benzodiazepines, narcotics, methadone,
alcohol ↓ FM
3. Maternal Conditions:
- Day2 of Bethamethasone administration FM ↓ - Thyrotoxicosis , Hypokalemia – baseline FHR
49% all values return to normal variability
Day4 transient effect
7. Smoking: - Maternal dehydration - ↑ FHR
- Maternal fever - ↑ fetal core temp.; ↑ FHR
- Test Reliability of CST
4. Fetal Conditions:
- Congenital Anomalies –heart block,
- (+) CST poor predictive value < 35%
- Management depend on:
anencephaly
1. age of gestation – Preterm , BACK-UP
5. Gestational Age:
BPS or Doppler. Term or Post term
- “Physiologic non-reactivity”
DELIVER
- NST in preterm infant :
2. Maternal Condition
15bpm amplitude not typical
< of organized fetal arousal states Biophysical Profile Scoring
(state F) common quiet sleep states - Basis:
(state 1F) Hypoxia Cascade
Embryogenesis
Low amplitude decelerations seen Fetal CNS centers
with FM FT Cortex/subcortical 7.5-8.5
(tone) area wks
FHR ↓ in both rest and activity
FM Cortex-nuclei 9 wks
periods with↑ in AOG (movement)
- Extend testing time and modifying criteria to FB 4th ventricle 20-21
10 bpm/accelerations reduce False (+) rate (breathing) wks
of NST. FHR Post. 24 wks Hypoxia
(heart rate) Hypothalamus
- NICHD ,1997 Research Guidelines for
medulla
Interpretation of FHR:
< 32 weeks –accelerations in
preterm fetus is >/= 10 bpm. , >/=
10 secs.
6. Poor predictor of chronic asphyxia: - Two categories:
- non- visualization of Amniotic Fluid 1. Acute biophysical variables:
- must be combined with BPS or AFV - altered immediately in the presence of fetal
measurement hypoxemia
- Clinical Efficacy of NST - FB, FT,FM, HEART RATE (NST)
2. Chronic Biophysical Variables:
- High False (+) Rate 80%
- Non-Reactive Test FURTHER EVALUATION
- requires a period of time before alterations
become visible Amniotic Fluid Volume – Fetal
(BPS , CST)
compensatory mechanism Blood flow
directed to essential organs (Brain, Heart,
Contraction Stress Test
Adrenals) non-essential organ (Kidney)
- Basis:
- Marginally compromised fetus w/ limited O2
- Amniotic Fluid Volume
reserve and limited placental function manifest
- Methodology:
w/ late decelerations when subjected to uterine
contractions. - curvilinear scanner
- Initial survey:
- Methodology: a. Fetal #,lie ,position
- Same with NST , 20 min. recording of FHR b. Placenta
c. Fetal morphometric data ( BPD,AC,FL)
and uterine activity.
d. Gen. Survey
- (-) Uterine contractions :
1. IV Oxytocin 3 cxns. In 10 mins. - Fetal Tone, Fetal Movement, Breathing, AFV
2. Nipple stimulation ( cost-effective , combined with NST for Full BPS , (-) NST Modified
shorter testing time. - Biophysical Profile Scoring
Variable Score 2 Score 0
1 nipple x 2 min. , rest 5 min. Fetal 30 sec. Sustained Breathing < 30 sec. Of fetal breathing
Breathing Movements movements in 30 mins.
In 30 min.
- Interpretation of CST Fetal 3 or > Gross Body Movements in 2 or < gross body movements in
- Negative – (-) Late decelerations or Movements 30 min.
Simultaneous limb and
30 min.
observation
significant variable decelerations Trunk movements
- Positive – Late decelerations ff. by 50% or >
Fetal Tone 1 episode of motion of a limb fr.
Position of flexion to ext. w/
Semi or full limb extension w/
no return or slow return to
if frequency is < 3 in 10 min. return flexion
Fetal Heart FHR accels 15/bpm. Lasting for (-) accelerations or < 2
- Equivocal Suspicious – Intermittent late or Rate 15 secs. W/ FM for 20 min. Of FHR in 20 min.
significant VD present in one contraction AFV AF pocket 1 cm. In 2 AF pocket < 1 cm. In
planes 2 planes
- Equivocal Hyperstimulatory – FHR decels. in
cxns. > 2 min. or > 90 secs. - BPS Interpretation
- Unsatisfactory - < 3 cxns. In 10 min. or
BPS Score
10
Interpretation
Normal Non-
Management
(-) indication for delivery weekly testing
uninterpretable trace asphyxiated DM 2 x a week
8/10 N AF 8/8 Normal Non- (-) indication for delivery Rpt. Test /protocol
asphyxiated
8/10 ↓ AF Chronic fetal DELIVER
asphyxia
suspect
6 Possible fetal AF abn. DELIVER
asphyxia <36 wks. N AF Cx favorable Deliver, if < 36 wks.
LS ration<2 ,Cx unfavorable , rpt.test in 24 hrs. ,
rpt. Test < Deliver
>6 Observe
4 Possible fetal Rpt.test same day < 6 deliver
asphyxia
0 to 2 Almost certain DELIVER
asphyxia
CST (+) CST (-)
- Modifications in BPS
- Limitations of CST
Selective use of NST when all other 4 variables are
- Same limitations as NST
normal
- Limited application :
Substitution of AFI for vertical pocket
Multiple Pregnancy
NST/AFI – complete BPS for abn. NST or AFV
Preterm Labor
Hx. Of Uterine Rupture BPS & Placental Grade – scoring 3 for intermediate
Placental Abnormalities variable VAS
Classical CS scar
- Timing and Frequency of BPS 7. Polyhydramnios
Time and frequency variable Individualized - Maternal Diseases w/ polyhydramnios (DM,
approach “ Disease specific testing “ Multiple Pregnancy, Hydrops) cannot be
Testing not started at AOG where active assessed because no score,only in
intervention not possible oligohydramnios
More immature fetus more abnormal score to 8. Inability to provide an estimate of fetal reserve
warrant delivery - Waxing and waning of BPS parameters in
Take into consideration maturation of CNS centers sustained hypoxemia indistinguishable fr. N
BPS activities. This is because of fetal
- Limitations of BPS compensation & resetting of sensitivity.
Sudden insult (abruptio), superimposition of
1. Fetal rest activity cycles: 2nd insult ( uterine cxns.)
Fetus variation in sleep states average 20-30
- Test Reliability:
min. more pronounced with fetal maturity
REM stage – FB present 30-75% of time, apnea
- Corrected Perinatal Mortality Rate: 0 –
26.4/1000
pds. brief, GBM more frequent, FT diminished
- False (-) rate : 0.078-2.28
Non- REM –FB 14- 35% ,apnea pds. long so
that if < 30 min. observation of absent FB - The average interval between last normal
may not be due to hypoxia FT increased, GBM score and fetal death was 3.62 days
diminished (placental & cord accidents)
2. Maternal Glucose level:
Doppler Velocimetry
↑ incidence of FB after meals.
↑ in FB in the 2nd. & 3rd hr. after a 800kcal.
Meal during the last10 wks. of pregnancy
No association with meals and incidence of
GBM and FT.
3. Gestational Age:
FB seems to ↑ with advancing AOG 24-28 wks.
–14% of time , 19 wks- 6%, 10 wks- 2%
GBM & FT – move more often at earlier AOG ,
more sporadic and shorter
4. Alcohol and Smoking:
FB– inhibited by alcohol , 20 oz. Of alcohol in
Doppler Shift
healthy pregnant women inhibit FBM x 3hrs
not reversed by glucose - Spectral analysis:
Smoking –controversial 1. Quantification of flow – unreliable
• 2 cigarettes ↓ FB 2. Doppler wave form analysis – waveform from an
• ↓ in rate but not incidence arterial source represent arterial velocity
waveform and is configured by upstream and
• Nicotine – effect on uterine vasculature downstream circulatory factors.
causing fetal hypoxemia, direct effect
on fetal respiratory drive GBM & FT – not
affected by Smoking and Alcohol
5. Labor:
FB – initial fall in the rate with Braxton Hicks
cxns. With ↑ after
incidence ↓ during last 3 days prior to onset
of labor and during latent phase, abolished
during active phase
GBM & FT – no effect
6. Drugs
↓ FBM ↑ FBM
Anesthetics Cathecolamines Wave Form Analysis
halothane, adrenalin, B mimetics
Arterial Venous Other
thiopental Adenylcyclase inhibitors Umbilical Ductus Venosus Coronary sinus
Barbiturates Prostaglandin synthetase MCA Inferior Vena Cava Coronary arteries
Narcotics – morphine inhibitors –indomethacin Uterine Pulmonary artery
Aorta
Benzodiazepines Doxapram Renal Artery
Prostaglandin Internal Carotid
Pancuronium Artery
- Umbilical Artery
- CT Significant ↓
in CS for fetal
distress (-) effect
on perinatal
mortality
Conclusion
1. Methods and Limitations
2. NO tests superior
3. INTEGRATE whole clinical picture !! - fin -
AsM audrey_cl@yahoo.com