Evaluation of fetal growth and fetal well- being

Evaluation of fetal growth and fetal well- being

EVALUATION OF FETAL GROWTH AND FETAL WELL- BEING MARTYNA STANKIEWICZ FETAL WELL BEING eutrofic fetus-housed in the correct channels in the centile grids , which biophysical parameters are valid HISTORICAL METHODS NOW INAPPLICABLE (OUTDATED) Assessment level of: estriol- daily in the urine collection and in blood

as the biochemical hPL (human placental lactogen)- human chorionic somatomammotropin (hCS) capacity PAPPA exponents of hCG (human chorionic gonadotropin) a placenta

CURRENTLY: TESTS AND EXAMINATION OF THE BIOPHYSICAL counting fetal movements: recommended from 28. week of pregnancy (since when obstetric interventions shall be): -at least 2 periods of fetal activity: 10 express movements per hour during children's activity ( usually very early in the morning or late in the evening) -evaluation of fetal activity during the day- at least 10 times (applies to people very well sleeping/working) evaluation of the bottom of the uterus -measuring the distance from the pubic symphysis to the bottom of the uterus -ultrasonography:- fetal biometry -the amount of amniotic fluid -placenta maturity measurement -transverse cross section of the cerebellum -evaluation of fetal activity in ultrasound -doppler ultrasound

DOPPLER ULTRASOUND in the third trimester- in: umbilical artery middle cerebral artery umbilical vein ductus venosus coronary vessels ( ascending aorta) DOPPLER ULTRASOUND IN UMBILICAL ARTERY the risk of hypoxemia and acidosis fetus inversely proportional to end-diastolic flow in the UA

lack of / reverse of the end- diastolic flow appears, on average, a week before the decompensation of the fetus DOPPLER IN THE MIDDLE CEREBRAL ARTERY high resistance flow low flow in diastole blood flow in the MCA illustrates the brain oxygenation and the index of PI in the proximal MCA correlates with oxygen depletion MCA

BRAIN SPARING EFFECT lowering pulse rate PI testifies to the fetal hypoxiabrain sparing effect, which is a fetal adaptive reaction to placental insufficiency. due to placental insufficiency, the central nervous system is preferentially perfused, which is intended to maintain oxygen supply to the brain as much as possible the fetus adapts to placental insufficiency by vasodilatation of the cerebral circulation, which can be detected as a decreased pulsatility index in the cerebral arteries the indicator of the brain-sparing effect is a raised ratio between the umbilical artery pulsatility index and the middle cerebral artery

pulsatility index ( called the U/C ratio) increased diastolic cerebral flow through the brain in cases of hypoxia. BRAIN SPARING EFFECT The term brain-sparing refers to relative protection of the brain as compared with other organs during fetal development, but this does not guarantee normal development after birth Most commonly occurs as a response of the fetus on his hypoxia caused the bearing factor DUCTUS VENOSUS

is a vessel, that carries oxygen-rich blood from the umbilical vein in such a way as to be able to bypass the liver and provide as much oxygen to the brain and upper half of the body of the fetus has a beginning on the posterolateral lower surface of liver from a combination of left umbilical vein with the left branch of the portal vein and end up bumping into the inferior vena cava, right by the end of the absorbing left the portal vein. within the venous system regulatory mechanism works similar to the sphincter, reducing excessive uterine muscle contraction during the venous return. the specter of blood flow in every heart cycle has two maximums corresponding to the contraction and relaxation of the ventricles and the minimum corresponding to atrial relaxation the correlation between abnormal flow spectrum in DV and fetal acidosis

evaluation of blood flow is the calculation of the pulse ratio for veins and wave A height (atrial contraction), which should not be negative or zero. DOPPLER IN THE VENOUS DUCT (DV) UMBILICAL VEIN in physiological conditions this flow is laminar and steady at the time of the chest movements of the fetus may appear wavy flow as a variant of the standard

but slightly, wavy angular frequency is a symptom of pathology, which is likely to be indicative of an increased systemic venous pressure, for example, in the course of circulation failure of the fetus Planck angular frequency is a picture of late-diastolic recurring decrease in blood volume flowing in the umbilical vein for pulsation is probably responsible return flow in the vein of the lower main during atrial contraction (a symptom of damage to the heart) UA AND UV CARDIOTOCOGRAPHY (CTG)

sometimes known as electronic fetal monitoring the most commonly used test for antepartum and intrapartum fetal surveillance in the majority hospitals of developed countries records changes in the fetal heart rate and their temporal relationship to uterine contractions CARDIOTOCOGRAPHY 110 - 160/MIN NORMAL FETAL CARDIAC ACTIVITY > 160/MIN -TACHYCARDIA

< 110/MIN -BRADYCARDIA Fetal tachycardia nervousness mother fever fetal infection embryo/foetal anaemia fetal hypoxia Fetal bradycardia fetal hypoxia hypotension or shock mother's umbilical cord compression Abruption

prematurity defects (blocks) of the heart of the fetus cigarette smoking vagus nerve boost an overactive thyroid gland inferior vena cava syndrome CARDIOTOCOGRAPHY

Acceleration transient increased FHR by 15 strokes over 15 '' appear in conjunction with the movements of the fetus : uterine contractions are accompanied by the exponent of the welfare of the fetus Deceleration periodic lowering of FHR usually arising in connection with the contractions of the uterus early (stimulation of n. X during the heads tribulation in the canal ) late (exponent of placental insufficiency)

variable (compression of the umbilical cord) CARDIOTOCOGRAPHY- NON STRESS TEST (NST) a simple non-invasive test that can serve as screening tool to detect fetal distress already present or likely to develop and prevent unnecessary delay in intervention maternal perception of fetal movements evaluation of the accompanying acceleration movements of the fetus provides direct and valuable information about neurological and myocardial function of the fetus

reactive (in 30 min record at least two acceleration) non- reactive (no acceleration during 60 min) OXYTOCIN CHALLENGE/ CONTRACTION STRESS TEST (OCT) The purpose: to assess the fetal heart rate response to contractions The results may be used to aid the decision making proces regarding mode and timing of delivery Indications: this may include, patients with high risk pregnancies (presence of disease state in mother or fetus) or previous testing that may have indicated compromised fetal status Interpretation : is based on the presence or absence of late decelerations, defined as decelerations that start after the nadir of the contraction and persist beyond the end of the contraction Initial Vital Signs are assessed and the external monitor is applied - a continuous FHR tracing must be maintained for

the duration of the test Fetal heart rate baseline and current level of uterine activity must be established prior to the initiation of the Oxytocin infusion If current uterine activity consists of three contractions of at least forty seconds duration occurring within a ten minute period, the fetal heart rate response to these contractions will be evaluated the test is complete if the level of uterine activity does not meet the above criteria Oxytocin will be given to stimulate or increase uterine contractions OXYTOCIN CHALLENGE/CONTRACTION STRESS TEST (OCT) The OCT will be interpreted using the following criteria: NEGATIVE: no late or significant variable decelerations POSITIVE: late decelerations following 50% or more of contractions (even if contractions are fewer than three in 10 minute window)

EQUIVOCAL- SUSPICIOUS: intermittent late decelerations or significant variable decelerations- requires repeat testing on following day EQUIVOCAL- HYPERSTIMULATORY :fetal heart rate decelerations that occur in the presence of contraction more frequent than every two minutes or contractions that last longer than 90 seconds- requires repeat testing on following day. [1] UNSATISFACTORY: fewer than three contractions in 10 minute window or an uninterpretable tracing (quality of the tracing renders interpretation impossible)- requires repeat testing on following day A positive CST indicates high risk of fetal death due to hypoxia and is a contraindication to labour- usually consider operative delivery in such situations OXYTOCIN CHALLENGE/ CONTRACTION STRESS TEST (OCT) Is a method being used to evaluate utero-placental respiratory function before labor Is done by recording fetal heart rate and uterine contractions on a strip chart by means of a suitable

external fetal monitor the FHR response of late deceleration suggest s utero-placental respiratory insufficiency Uterine contractions are known to interfere with uterine blood flow and are used in this test to provide an intermittant hypoxic stress to the fetus The test gives rapid information about fetal well- being Has not been asssociated with an increased incidence of premature labour OCT FETAL BIOPHYSICAL PROFILE (BPP) a prenatal ultrasound evaluation of fetal well-being involving a scoring system, with the score being termed Manning's score

has 5 components: 4 ultrasound(US) assessments and a nonstress test(NST) The five discrete biophysical variables: Fetal movement Fetal tone Fetal breathing Amniotic fluid volume Fetal Heart Rate BIOPHYSICAL PROFILE (BPP)

Each assessment is graded either 0 or 2 points, and then added up to yield a number between 0 and 10 A result of 8 or 10 points is generally considered reassuring The presence of these biophysical variables implies absence of significant central nervous system hypoxemia/acidemia at the time of testing Each of the movements evaluated in the BPP results from efferent signals originating in different central nervous system (CNS) centers CRITERIA FOR CODING FETAL BIOPHYSICAL VARIABLES AS NORMAL OR ABNORMAL Biophysical Normal Abnormal

Variable (Score = 2 (Score = 0) Fetal breathing movements 1 or more episodes of 20 s within 30 min Absent or no episode of 20 s within 30 min Gross body movements

2 or more discrete body/ limb movements within 30 min (episodes of active continuous movement considered as a single movement) < 2 episodes of body/limb movements within 30 min Fetal tone 1 or more episodes of active extension with return to flexion of fetal limb(s) or trunk (opening and closing of hand considered normal tone)

Slow extension with return to partial flexion, movement of limb in full extension, absent fetal movement, or partially open fetal hand Reactive FHR 2 or more episodes of acceleration of 15 beats per 1 or more episodes of acceleration of fetal heart rate or acceleration of < 15 bpm within 20 min minute (bpm) and of >15 s associated with fetal movement within 20 min Qualitative AFV 1 or more pockets of fluid measuring 2 cm in

vertical axis Either no pockets or largest pocket < 2 cm in vertical axis BIOPHYSICAL PROFILE (BPP) BPP Recommended management <=2 Labor induction

4 6 Labor induction if gestational age >32 week Repeating test same day if >32 weeks, then delivery if BPP<6 Labor induction if >36 weeks if favorable cervix and normal AFI Repeating test in 24 hours if <36 weeks and cervix unfavorable; then delivery if BPP <6, and follow-up if >6 8 Labor induction if presence of oligohydramnios THANK


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