1. ASSESSMENT OF FETAL WELLBEING Max Brinsmead MB BS PhD May 2015

2. The fetus is unique because...  He or she cannot signal health by way of history  We can only examine through his or her mother  Non-invasive evaluation includes...  Documentation of size and growth  Fetal movements & reaction to stimuli  Fetal heart rate studies using CTG  Amniotic fluid volume study  Looking at placental morphology by ultrasound  Study of blood flow in various fetal and maternal vessels – Doppler studies  Placental endocrine studies in maternal blood and urine

3. Pregnancies can be divided into those that are High or Low Risk of Fetal Compromise/Death  High risk pregnancies include those that...  Occur with conditions known to impair feto-placental function e.g. Maternal hypertensive conditions, Auto immune disease  Depart from normal growth on clinical assessment i.e. “Too big” or “Too small”  There is a poor obstetric history  Multiple pregnancy  Occur with multiple risk factors e.g. Low social class, ethnic risk, smoking or other drug use etc

4. Umbilical Artery Doppler Study  Upper panel represents peak (systolic) and trough (diastolic) flow often expressed as S/D ratio  Lower panel is constant flow through a uterine vein  UA Doppler reflects downstream placental resistance  Is the 1 st change to occur with placental disease

5. Umbilical Artery Doppler changes with Gestation

6. Abnormal UA Doppler Flows  When flow ceases in the diastolic phase (AEDF) the S/D ratio is very high ( ∞)  Flow may even reverse in the diastolic phase (RDF) as shown opposite

7. Uterine Artery Dopplers…  Are of limited use when… ▪ The fetus is very premature (<30 weeks) ▪ Pregnancy is prolonged (>40 weeks) ▪ It is a low risk pregnancy ▪ 5% will be high but normal ▪ Are useful in High Risk Pregnancies ▪ May be used to prolong pregnancy with immature fetus and apparent IUGR ▪ Have a high negative predictive value for fetal death ▪ Will change 4 – 7 days before other changes in fetal wellbeing e.g. Biophysical Profile

8. Other Pregnancy Doppler Studies  Fetal Middle Cerebral Artery Resistance falls as brain-sparing IUGR begins Strong correlation with fetal HB Of particular use in monitoring intrauterine haemolysis  Fetal Ductus Venosus Resistance rises as the placenta deteriorates  Maternal Uterine Arteries Increased resistance with bilateral notching at 12 – 24w predicts early (but not late) onset pre eclampsia with ≈ 60% sensitivity

9. Uterine Artery Doppler

10. Fetal Biophysical Profile  Ultrasound for… Fetal Breathing Fetal Movements Fetal Tone Amniotic Fluid Volume  Non Stress CTG Looking at fetal heart short term variability and accelerations  Assigns a score of 0,1,2 to each of these five measures as with the Apgar Score  Scores ≤ 6 are abnormal

11. Fetal Biophysical Profile (Manning)

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