1. Fetal Wellbeing Dr Hsu Chong NIHR Clinical Lecturer in Obstetrics & Gynaecology Warwick Medical School

2. Lecture Learning Outcomes Define the fetal period Outline the developmental processes that occur during the fetal period Understand the chronology of development of the major body systems Describe the factors that influence viability Describe the pattern of increase of fetal size, weight and body proportion Outline techniques used to assess fetal growth and development Describe processes involved in control of amniotic fluid volume Describe the changes in fetal physiology that occur at birth

3. Lecture Synopsis This lecture will describe the timing and development of the major body systems and how the growth and development of the fetus is assessed during a normal pregnancy.

4. Why bother? Stillbirth rate 3.8-5.3/1000 (CEMACE 2009) – Unexplained 28% Intrauterine Growth Restriction – Major congenital anomaly 9%

5. Gardosi et al. BMJ 2013.

6. Ultrasound in Obstetrics

7. Ultrasound

8. Periods of assessment of fetal wellbeing 1 st 2 nd 3 rd Intrapartum monitoring

9. First trimester Fetal period- Week 9 to birth Assessment of gestational age using Crown to Rump Length (CRL) Measurement of the nuchal translucency (weeks 11- 13+6) CRLNuchal translucency + +

10. Fusion of the neural tube Spinal cord Image from STRATOG

11. Gut herniation

12. Mid-trimester ultrasound 18+0 to 20+6 Fetal anatomy Placental site http://fetalanomaly.screening.nhs.uk/fetalanom alyresource/whats-in-the-hexagons1/about-the- scan/the-base-menu

13. Symphysio-fundal height

16. Fetal growth Estimated weight calculated from – Head circumference – Abdominal circumference – Femur length

17. Fetal growth Symmetric vs asymmetric growth restriction – HC and AC similar – Reduction in AC to preserve brain development Small for gestational age Fetal growth restriction – Growth under 10 th centile

19. Biophysical profile Components – Fetal movement – Resting tone – Breathing movements – Amniotic fluid volume

20. Doppler ultrasound Colour flow doppler Red: racing toward probe Blue: ”cold” i.e moving away

21. Uses of Doppler ultrasound Assessment of fetal wellbeing – Measure flow in umbilical artery Assessment of fetal anaemia – Measure flow in Middle Cerebral Artery ? Timing of delivery

22. Does intervention improve outcome?

23. Timing of delivery vs risks of prematurity Intramuscular corticosteroids reduce risk of death and disability – Type II pneumocyte maturation Grace Hayes Grace Research Fund Grace Hayes Grace Research Fund

24. The Epicure studies Moore et al. BMJ 2012 http://www.bmj.com/content/345/bmj.e7961

25. The Epicure studies Moore et al. BMJ 2012 http://www.bmj.com/content/345/bmj.e7961

26. Birthweight as a factor influencing survival Draper et al. BMJ 1999 http://www.bmj.com/content/319/7217/1093

27. Cardiotocography

28. Baseline and acceleration

29. Variability

30. Deceleration

31. NICE classification of Fetal Heart Rate features CG55 Intrapartum care

32. CTG High negative predictive value – i.e when normal, fetal acidaemia unlikely – When abnormal, fetus acidaemia could still be unlikely Used antenatally – Changes may reflect the end stage process of chronic hypoxia

33. Fetal scalp blood sampling

34. Intrapartum – Fetal scalp sampling Capillary sample Immediate delivery indicated when pH less than 7.20

35. Summary Ultrasound is main investigation for assessment of fetal well being Assessment of anatomy Growth assessment & umbilical artery dopplers may aid decision to deliver Continuous CTG monitoring required for high risk pregnancies

36. In your spare time Youtube videos – The human body (BBC production with Sir Richard Winston) UNSW site for embryological and fetal development – http://embryology.med.unsw.edu.au/embryology/index.php?title=Fetal_Developm ent Mid trimester scan – http://fetalanomaly.screening.nhs.uk/fetalanomalyresource/whats-in-the- hexagons1/about-the-scan/the-base-menu Premature labour- patients’ perspective – http://freddiemcgill.blogspot.co.uk/ RCOG guideline No 31 – Small for gestational age fetus, Investigation and Management