I. Fetal movements II. Fetal breathing movements III. Contraction stress test IV. Non-stress test V. Biophysical profile VI. Amnionic fluid volume VII. Umbilical Artery Doppler Velocimetry Current recommendations Significance of fetal testing

- In the 1 st William obstetric edition 1903: FHR > 160 b/m or < 100 b/m is dangerous - Now the fetus is considered as a 2 nd patient and exposed to serious morbidity and mortality > his mother - Fetal testing is now extended to the embryonic life: e.g. Embryonic HR may predict pregnancy outcome

Our goal is to prevent fetal death Fetal death within 7 days of a normal test is very rare In most tests: +ve predictive value (true +ve) = 99.8% --ve predictive value of abnormal tests (true –ve) = 10 – 40%

- FMs starts at 7 th week - At 8 th week  FMs are never absent > 13 minutes - At 20 – 30 weeks  organization of FMs ( rest - activity cycles) - In the 3 rd trimester until 36 weeks  maturation of FMs - > 36 weeks  behavioral states

FHR FMs 1F quite sleep vvvvvv no 2F active sleep VVVVV I 3F VVVVV no 4F awake state VVVVV IIIIII + FHR accelerations The presence of F3 is debate Continuous eye movements are present in: 2F, 3F, 4F

At 38 weeks 75% of the time 1F&2F Study: Urinary bladder ↑ in 1F and ↓ in 2F Sleep – awake cycles: Sleep  minutes Mean = 23 minutes Maternal perception of FMs is described as: weak - strong - rolling

FMs is α to AFV: As GA ↑ > 20 weeks  weak FMs ↓ vigorous FMs ↑ > 32 weeks strong FMs ↓ due to:  ↓ AFV  ↓ space Normal FMs: = 4 – 10 FMs / 12 hours

In 1973  ↓ FM precede fetal death Methods of measuring FMs:  Tocodynamometer  U/S  Maternal perception Study: Maternal perception = 80% of FMs by U/S Study: - > 36 weeks, maternal perception = 16% - Longer FMs > 20 seconds are better felt

Optimal number and duration of FMs: Not defined Study: Normal FMs = 10 FMs/2 hours Study: FM/1 hour is good if ≥ previous count Patient complaint of ↓ FMs in the 3 rd T: Not uncommon = 7%  same pregnancy outcome  Evaluate & reassure

NST is indicated if:  Abnormal fetal growth by U/S  Abnormal Doppler Study: Mean duration to record 10 FMs = 2.7 hours of counting/day Study: Asking mothers about FMs each visit = counting FMs

In 1972  inward and outward flows of tracheal fluid in sheep = BMs BMs differ from FMs:  Paradoxical = inspiration collapse expiration distend  Not continuous May be coughing to expel AF debris Essential for fetal development

Types of BMs:  Gasps/sighs = 1 - 4/minute  Irregular bursts = up to 240c/m As GA ↑  BMs rate ↓ & volume ↑ At 33 – 36 weeks = lung maturation weeks  diurnal variation:  ↑ after meals  ↓ at night

If BMs are not seen  extend U/S evaluation for up to 2 hours before diagnosis of absent BMs Factors affecting BMs: Hypoxia Sound Hypoglycemia Cigarette Labor FHR Impending PTL GA Amniocentesis

BMs as a marker of fetal wellbeing: Unfulfilled because multiple factors it affect it, but it is included in BPP with Other indices

Basis: Uterine contractions  ↑ amnionic fluid P  collapse of uterine vessels  isolation of intervillous space  transient ↓ O 2 exchange If uteroplacental pathology is present  late decelerations

CST is present since 1972 Late decelerations: Start at/or beyond the acme of uterine contraction Disadvantages: Require 1 ½ hours

Method: Oxytocin 0.5 mIU/minute by infusion pump doubled /20 minutes  3 contractions in 10 minutes duration of each ≥ 40 seconds Nipple stimulation: 1 nipple is rubbed through her clothes for 2 minutes or until contractions start, restart After 5 minutes  3 contractions in 10 min Advantages: ↓ time and cost May  hyperstimulation with mild FD

Negative: No LD or significant VD Positive: LD + 50% of contractions even if contractions are < 10/m Equivocal-suspicious:  Intermittent LD  Significant VD Equivocal-hyperactive:  LD + > 3 contractions/10m  Contraction > 90 seconds Unsatisfactory:  < 3 contractions /10m  Uninterruptable tracing

1975 Basis: FMs  FHR accelerations = good sign Equipments:  Doppler  Maternal perception of FMs Differ from CST and much easier Used to discriminate false +ve CST Used in BPP

Physiology: Beat to beat variability > 5 b/m + FHR accelerations = good autonomic function Most common causes of no accelerations:  Fetal sleep  Drugs As GA ↑  ↑ FMs + ↑ FHR accelerations 25 – 28 weeks accelerations are  70% 15 b/m for 15 seconds 90% 10 b/m for 10 seconds < 32 weeks use 10 b/m for 10 seconds

Normal NST: Vary in number, amplitude & duration of acceleration = ≥ 2 accelerations that peak at ≥ 15 b/m for ≥ 15 seconds in 20 minutes ± FM 1 acceleration is enough by some If no accelerations  extend examination to minutes before diagnosis of nonreactive NST

No accelerations = not bad fetus False +ve NST ≥ 90% Disadvantages of NST:  ↑cost  Irreducibility Computerized analysis:  ↓ cost  Reliable  objective

Abnormal NST: - Silent oscillatory pattern = ominous = beat - to - beat variability < 5 b/m + no accelerations - Terminal cardiogram: Both + LD = uteroplacental insufficiency

Abnormal NST is associated with: FGR 75% Oligohydramnios 80% Acidosis 40% Meconium 30% Placental infarction 93% Study: Nonreactive NST for ≥ 90 min is associated with ↑ perinatal pathology in 93%

Interval between tests: 1/week 2/week, 1/day, > 1/day in:  Postterm  Type 1 DM  FGR  PIH

Decelerations: Normally present in ½ to 2/3 of fetuses Variable decelerations: Not ominous if nonrepetitive and brief < 30 seconds Repetitive VD ≥ 3 /20 minutes even if mild are associated with ↑ CS for FD Decelerations ≥ 1 min  bad prognosis

Study: - Addition of NST to AFV  75% CS for FD in cases of ↑ VD + ↓ AFV - FD in labor + normal AFV is increased in patients with VD False - normal NSTs: = fetal death within 7 days of a normal NST

Mean interval between testing and death: = 4 days Range: = days Most common indication of NST: = postterm Most common autopsy findings:  Meconium  Abnormal umbilical cord

= Acute asphyxial insult = NST is inadequate to preclude such an acute asphyxial events Other causes:  Fetomaternal Hg  Infection  Abruptoplacenta  Congenital anomalies  Abnormal cord insertion

Acoustic Stimulation Tests: Artificial larynx  acoustic stimulation to ↑ acceleration Method: External sound for 1 – 2 seconds Repeat 1 – 3 times for up to 3 seconds Still under evaluation

Manning & colleagues variables to ↓ false +ve ↓ false –ve results Equipments:  Doppler  Real time U/S Duration of testing: 1/2 – 1 hour

2 0 NST ≥ 2 accelerations < 2 (≥15 b/m for ≥15 sec in 40 minutes) FBMs ≥ 1 ≥ 30 sec in 30 m < 30 sec FMs ≥ 3 in 30m < 3 F Tone ≥ 1 -- AFV > 2 cm ≤ 2 cm ( largest single vertical pocket)

Fetal tone = flexion and extension of one limb or opening or closing hand NST is not required if the 4 variables are normal AFI if the largest vertical pocket is ≤ 2 cm  should be evaluated BPP = 6 is equivocal and poor predictor of abnormal outcome BPP = < 6 is progressively more accurate predictor of abnormal outcome

Study: BPP followed by cordocentesis for pH: - 20% of fetuses are FGR - 80% of fetuses have alloimmune hemolytic anemia BPP = 0 is associated with acidemia BPP = is associated with normal pH

Study: BPP+cordiocentasis in DM  no benefit Study: BPP+cordiocentasis in GR  no benefit The morbidity and mortality in GR depend on GA & wt not BPP results Modified BPP( abbreviated BPP 1989): = vibroacoustic NST + AFV X 2/week Duration of testing = 10 minutes

If AFV is < 5 do complete BPP or CST CST  ↑CS for false abnormal results Acceptable by ACOG False –ve rate = 0.8 : 1000 False +ve rate = 1.5 : 1000 Study: Excellent method with no unexpected FD

BPP = 10:  Repeat 1/w 2/w in DM & postterm BPP = normal AFV:  Repeat BPP = ↓ AFV: Chronic fetal asphyxia suspected  Deliver

BPP = 6: Possible fetal asphyxia If > 36 weeks + normal AFV + favorable cervix  deliver If < 36 weeks + normal AFV  repeat: if ≤ 6  deliver if > 6  repeat If + ↓ AFV  deliver

BPP = 4: Probable fetal asphyxia  repeat same day if ≤ 6  deliver BPP = 0 - 2: Almost certain fetal asphyxia  deliver

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Basis: Uteroplacental insufficiency  ↓ fetal renal blood flow  ↓ urine production  ↓ AFV Methods:  AVI  Largest vertical pocket  2 x 2 cm pocket

Study: AFI < 5 cm  ↑ CS for FD ↑ low 5 minutes Apgar score ↑ perinatal morbidity & mortality Study: 20% of fetuses have AFI < 5 cm AFI = poor diagnostic test Study: Same results in severe preeclampsia

Study: Nonintervention to permit spontaneous VD in fetuses with AFI < 5  same pregnancy outcome as induction of labor

Basis: To assess blood flow by characterizing downstream impedance Uterine artery S/D ratio: Most commonly useded, abnormal if: - ↑ 95 th percentile for GA - Diastolic flow is: Absent (perinatal mortality = 10%) Reversed (perinatal mortality = 33%)

Both absent and reversed diastolic flow are associated with IUGR Study: NST = Doppler Study: No benefit other than suggesting GR Study: No benefit in other diseases as: PIH, DM, lupus anticoagulant, postterm

Middle cerebral artery S/D ratio: May reflect fetal compromise Based on brain sparing theory: = uteroplacental insufficiency  ↑ blood flow + ↓ impedance Study: No significant difference Still under evaluation

No agreement for the best test All tests have different end points that are considered according to the clinical situation When to start? Most important considerations in deciding when to start:  Prognosis of neonatal survival  Severity of maternal disease In high risk patients at 32 – 34 weeks In more severe cases at 26 – 28 weeks

Frequency of testing: ≥ 1/week In parkland hospital: All high risk patients are admitted NST 2 – 3/week for admitted cases If FHR accelerations + Deceleration  No need for delivery If ↓ FMs or ↓ AFV in 3 rd T  Admission in labor suit

According to results of NST the patient is:  Discharged  Transformed to high risk ward  Delivered Fetal deaths in high risk patients are low Most fetal deaths are in low risk patients due to unpreventable events as:  Placental abruptions  Cord accidents

Does it make any difference? Fetal surveillance in 1970s = < 1% in 1980s = 15% Fetal death rate ↓ in high risk tested patients # untested patients Study: NSTs/CSTs are not recommended because of ↑ cost

Study: No benefit of testing  forms of care likely to be ineffective or harmful Can we identify fetal asphyxia early enough to prevent brain damage? Study: Abnormal NST is associated with ↓ cognition # Doppler = by the time fetal compromise is diagnosed, brain damage is already sustained

Study: CP in high risk patients managed by BPP = 1.3 : 1000 live birth # 4.7 : 1000 in controls In a prior report: CP is associated with ↓ BPP scores = identification is too late

In the last 2 decades: - Methods are continuously evolving = dissatisfaction - Wide range of normal variables: How many accelerations–FMs–FBMs duration and frequency of testing - Abnormal results are seldom reliable = forecast fetal wellness rather than illness