1. IN THE NAME OF GOD

2. BIOPHYSICAL PROFILE B.P.P

3.  In 1980 Manning and colleagues introduced BPP for evaluation of the fetus.  BPP is a noninvasive test that predicts the presence or absence of fetal asphyxia  BBP combines data from two sources: - FHR monitoring -Ultrasound

4. B.P.P  Fetal Heart Reactivity (NST)  Fetal Breathing Movement  Fetal Movement  Fetal Tone  Amniotic Fluid Volume

5. Pathophysiology Tissue hypoxia  stimulates the aortic & carotid chemoreceptors (extremely high metabolism)  cardiac output redistribution away from fetal kidneys & viscera &limbs in favor of the brain, heart, placenta and adrenal glands ( redistribution)

6. Cont.  Chronic hypoxia  olygohyramnios: 1-decreased renal perfusion&^^ ADH 2-^^ fetal lung resorption 3-^^fetal swallowing 4-decreased fluid in amniotic space  ^^pressure umbilical cord  decreased perfusion  progression of hypoxia/ acidemia  cerebral edema and heart failure  poor perinatal prognosis  high mortality & morbidity

7. Fetal Central Nervous System Centers  Fetal Tone / 7.5 to 8.5 wcortex (sub cortical area)  Fetal Movements /9 wcortex nuclei  Fetal Breathing Movement /21 wVentral surface of the 4 th ventricle  Nonstress test /24-26 wpost. hypothalamus, medulla Emberyogenesis Hypoxia Hypoxia  cellular function change (special neuronal tissue)

8. CONT.  The centers regulating fetal movement have a higher threshold than those for fetal breathing or FHR accelerations; the fetal tone center has the highest threshold.  Heart rate reactivity would be the first parameter to be alerted, and fetal tone the last.  When the NST is reactive, the presence of fetal acidemia is R/O.

9.  The BPP highly correlates with the ante partum fetal umbilical venous cord PH level.  Heart rate reactivity & fetal breathing are inhibited at PH <7.20  Fetal body movements & fetal tones disappear at PH <7.10

10. VariableScore 2Score 0 Fetal Breathing Movements 1 or more episodes lasting at least 30” /30` No episodes of 30” duration Fetal Movements 3 or more gross body or limb movements in 30` 2 or fewer body or limb movements in 30` Fetal Tone At least 1 episode of motion of a limb (from extension to flexion) or trunk /opening& closing of hand Slow extension or partial flexion /hand remains open Fetal reactivity 2 or more accelerations of15 beats per minute lasting 15” in 20` No or less than 2 accelerations FHR in 40` Amniotic fluid volume At least 1 pocket measuring 2 cm Largest pocket of amniotic fluid<1cm

11.  There are 2 scoring systems: -The original BPP described by Manning et al. 10/10 -Vintzileos et al in 1983 proposed another scoring system,which gave intermediate scores (0,1,2), and also included placental grading as one of the biophysical variables.12/12

12.  More than 90% of tests that are normal are completed within the first 4’,and average testing time is less than 8’.  Some have suggested using fetal acoustic stimulation to shorten the period for testing.

14. Fetal breathing  Fetal breathing movements should be considered present only if they are continuous for at least 20”-30”, with breath-to-breath intervals of less than 6”.  hiccups also count as breathing movements  Scoring: ->1 episode of “breathing”>30”in 30’=2 points -No episode of “breathing”>30” in 30’=0 points

15. CONT.  Fetal breathing movements & fetal activities are reduced during maternal fasting  The unusual presence of CONTINUOUS MONOTONOUS fetal breathing, with complete absence of all other behavior for an extended period, may indicate acidosis, especially in diabetic fetus

16. Body Movement  Gross motor activities : -body/ trunk roll -spine flexion or extension -gross limb movement  Fine-motor activities: -eye movement -sucking /swallowing  Scoring: ->3 movements in 30’=2 points -<3 movements in 30’=0 points

17. Fetal tone  Active limb movement -Flexion  extension  flexion -Hand opens and closes  Scoring: ->1 episodes in 30’=2 points - 0 episodes in 30’=0 points

18. Amniotic fluid (AF) volume  Largest AF pocket is found : in vertical & transverse measurement  Different than 4 quadrant Amniotic Fluid Index/AFI  Use color Doppler for AF assessment - help avoid measurement of cord in AF pockets  Careful attention to transducer pressure is required to avoid a false diagnosis of oligohydramnios  Scoring: ->1 pocket of fluid > 2cm × 2cm=2 points -No pocket of fluid > 2cm × 2cm=o points

19. CONT.  The BPP is a combination of acute & chronic markers reflecting fetal well-being  acute : -fetal heart rate reactivity -fetal breathing movements -fetal movements -fetal tone  chronic: amniotic fluid volume #3 wks for significant oligohydramnios to develop

20. Cont.  The only score that is allowed to stand after the US variables have been evaluated is 8/8.  A score of “6/8” is not a BPS.  When the 4 US variables are performed first (modification), if any of these is absent, NST (only 10%) must be performed before the BPS is complete, and the score will be x/10.  Modification reduced the need for NST in 95 percent of cases and the average testing time per patient without reducing the predictive value of the test.

21. Modified B.P.P  The modified biophysical profile was developed to simplify the examination and reduce the time necessary to complete testing.  It is consisting of an NST & AFI  The rate of stillbirth within one week of a normal test is the same as with the full BPS, 0.8 per 1000 women tested.  The AFI is derived by adding the largest vertically measured pocket from each uterine quadrant.  Oligohydramnios is defined as an AFI of less than 6/ 5cm.  If either NST or the AFI is abnormal, a complete BPP or a OCT is performed

22. RESULTINTERPRETATIONRISK OF ASPHYXIA RECOMMENDED TREARMENT /MORTALITY 10/10 nonasphyxiated0%Conservative 1/1000 8/8 or10 (N.AF) nonasphyxiated0% 8/10 (ANL. AF) Chronic compensated asphyxia5-10%If mature ( >37w ), deliver If immature, serial testing (twice weekly) 89/1000 6/10 (N.AF) Acute asphyxia possible/equivocal test (repeat testing immediately, before assigning final value. If score is 6/10,then 10/10,in 2 continues 30’ periods, manage as 10/10) VariedIf mature ( >37w ), deliver If immature,repeat test in 24h & If < 6/10, deliver 50/1000 6/10 (ANL. AF) Chronic asphyxia &possible acute>10%If > 32 weeks, deliver If < 32 wk, test daily >50/1000 4/10 (N.AF) Acute asphyxia likely36%If > 32 weeks, deliver If < 32 wk, test daily 115/1000 4/10 (ANL.AF) Chronic asphyxia &acute asphyxia>36%If > 26 wk, deliver >115/1000 2/10 (N.AF) Acute asphyxia almost certain73%If > 26wk, deliver 220/1000 0/10 Score acute asphyxia virtually certain 100%Deliver immediately by cesarean section 600/1000

23. Cont. normal BPP a nonacidotic  A normal BPP (of >8) is considered predictive of a nonacidotic fetus. reduced AF risk of cord compression  The presence of oligohydromnios in either scoring system is considered abnormal, because reduced AF puts the fetus at risk of cord compression, death, or adverse perinatal outcomes, regardless the scores of the other biophysical parameters.