SEMINAR SEMINAR ONON

ANTENATAL FETAL ANTENATAL FETAL SURVEILLANACE SURVEILLANACE

PRESENTED BYPRESENTED BY::MS LISA CHADHAMS LISA CHADHA

MSC NURSING 1MSC NURSING 1STST YEAR YEARBVCON ,PUNEBVCON ,PUNE

DefinitionDefinition

Antenatal fetal surveillance is assessment Antenatal fetal surveillance is assessment of fetal wellbeing in antepartum period to of fetal wellbeing in antepartum period to ensure delivery of healthy neonate.ensure delivery of healthy neonate.

IndicationsIndicationsMaternal conditionsMaternal conditions

HypertensionHypertensionDiabetes mellitusDiabetes mellitusHeart DiseaseHeart DiseaseChronic renal diseaseChronic renal diseaseAcute febrile illnessAcute febrile illnessPneumonia /asthmaPneumonia /asthmaEpilepsyEpilepsyDrug AbuseDrug AbuseSickle cell diseaseSickle cell disease

Fetal conditionsFetal conditionsFetal growth Fetal growth

restrictionrestrictionRh isoimmunisationRh isoimmunisationFetal Cardiac Fetal Cardiac

arrythmiasarrythmiasFetal infectionsFetal infections

Pregnancy related condition

PreeclampsiaMultiple pregnancyPost term pregnancyDecreased fetal movementsAbnormal placentationPlacental abruption

Aims of Fetal MonitoringAims of Fetal Monitoring

Assuming satisfactory growth & wellbeing of Assuming satisfactory growth & wellbeing of fetus & mother throughout pregnancyfetus & mother throughout pregnancy

Screening high risk cases & adverse maternal Screening high risk cases & adverse maternal and/or intrauterine factors which affect the fetusand/or intrauterine factors which affect the fetus

Detecting early congenital anomalies and inborn Detecting early congenital anomalies and inborn metabolic disorders to decide early terminationmetabolic disorders to decide early termination

Objectives of Fetal SurveillanceObjectives of Fetal Surveillance

To determine gestational ageTo determine gestational age

To discover fetal congenital anomaliesTo discover fetal congenital anomalies

To detect abnormalities of fetal growthTo detect abnormalities of fetal growth

To detect & determine the severity of acute & To detect & determine the severity of acute & chronic fetal hypoxiachronic fetal hypoxia

Initiation of antepartum fetal Initiation of antepartum fetal surveillancesurveillance

EARLY PREGNANCYEARLY PREGNANCY

LATE PREGNANCYLATE PREGNANCY

EARLY PREGNANCYEARLY PREGNANCY

Early pregnancy Early pregnancy

BiochemicalBiochemical

A. Material serum alpha foeto protein

It is the onco protein It is produced by yolk sac & foetal liver.The highest level of the AFP in foetal serum &

amniotic fluid .Material serum level peak around 32 weeks .MSAP screening can be done between 15 - 21

weeks gestation (17 weeks is ideal)

MSAFP elevated atWrong gestational ageOpen neural tube defect of the foetus Multiple pregnancyIUFAnterior abdominal wall defectsRenal anomalies

MSAFP is low atTrisomies (Down syndrome)Gestational trophoblastic diseases neural tube defect

B. Triple test

It is combined biochemical test which includes MSFP, HCG & UE3 (unconjugated oestriol) .

It is used for detection of down syndrome .In an affected pregnancy level of MSAFP & UE3 tend to be low while that the HCG is high .

It is performed at 15-18 weeks .

C. Coomb’s test

Coomb’s test is used for Rh incompatibility.

if the coomb’ test is greater than 1:8 to 1:16 thann, amniocentesis is done for diagnosis of need for intrauterine transfusion.

It is used to detect presence or absence of the material antibodies on fetal red cells .

if there are no antibodies , the blood is retested at 28 & 34 weeks of pregnancy. 

D. Acetyl choline esterase(AchE)

It is elevated in most cases of open neural tube defects , it has got better diagnostic value than AFP.

E. Inhibin A

It is dimetric glycoprotein . it is produced by the corus luteum & the placenta.serum level of the inhibin A is raised in the women carrying a foetus with down syndrome

A. Florescence in Situ Hybridization(FISH)

FISH, or Fluorescence In Situ Hybridization, is a diagnostic prenatal test which looks for a few common chromosomal abnormalities mainly limited to Trisomy 13 (Patau syndrome), Trisomy 18 (Edward’s syndrome) and Trisomy 21 (Down syndrome) .

FISH does not have false positive results. If the fetal cells contain certain chromosomal abnormalities, this will be apparent with the FISH test.

The only exception might be if the parent has a chromosomal abnormality and the fetal cells were contaminated with parental cells.

 

B. DNA amplification using the polymerace chain reaction[PCR] It provides the convenient & efficient means of making millions of copies of a sort DNA sequence heating cooling cycles are used to denature to DNA & then build new widely used for assessing genetic variation , for diagnosing genetic disease & for forensic purpose.It can be made directly from fetus by amniocentesis chorionic villi sampling chrordiocentesis.

Amniocentesis

It is an invasive procedure, it is performed between 14-16 weeks of the pregnancy By inserting a needle through the abdominal wall into the amniotic sac . it is the procedure of the collection or removal os amniotic fluid(appro. 10-15 ml) colour of the amniotic fluid is usually in transparent colour .A yellowish tinge may suggest the blood incapability & green may suggest meconium staining

Indications

Genetic testing- Genetic amniocentesis done to detect certain conditions, such as Down syndrome.Fetal lung testing-  To determine whether the baby's lungs are mature enough for birth.Diagnosis of fetal infection-  To evaluate a baby for infection or other illness. The procedure also can be done to evaluate the severity of anemia in babies who have Rh sensitization — an uncommon condition in which a mother's immune system produces antibodies against a specific protein on the surface of the baby's blood cells.

TreatmentTo drain excess amniotic fluid from your uterus in case of polyhydrominos

Risks[1] Maternal :Infection Haemorrhage Premature rupture of the membrane and premature labour Maternal iso- immunization in Rh mothers

[2] FoetalAbortion Trauma Foeto maternal haemorrhage Oligohyromnios fetal lung hypoplasia Respiratory distress

Chorionic Villi Sampling

CVS is performed for prenatal diagnosis of genetic disorders .

It is carried transcervically between 10-12 weeks and transabdominally from 10th week to term. Diagnosis is obtained by 24 hours and as such termination is required it can be done safely in the first trimester itself .The technique is used in CVS are direct vision using a hysteroscope and transabdominal or transvaginal aspiration guided by ultrasound .

Transcervical: An ultrasound guides a thin catheter through the cervix to your placenta. The chorionic villi cells are gently suctioned into the catheter. This is the most common method.

Transabdominal: An ultrasound guides a long thin needle through the abdomen to your placenta. The needle draws a sample of tissue and then is removed. This procedure is similar to that of amniocentesis

Indication : chromosomal analysis – down syndrome and other chromosomal anomaly

DNA analysis – molecular genetic technique for the thalassaemia,sickle cell Diseases

Enzyme analysis –in born error metabolism

Chorionic villus sampling does not detect:Neural tube defects Rh incompatibility

Complications: foetal loss (1-2%) , oromandibular limb deformities , vaginal bleeding, limb reduction defects are high when CVS are less then 10 week of the gestation CVS when performed between 10-12 weeks are safe and accurate as that of the of the aminocentesis

Fetoscopy

This is the technique where by direct visualization of the fetus is undertaken via an endoscope A cannula 2.4,3.0 mm in diameter with a selfoscope 1.7mm in diameter , attached to a microscope and with the fine glass fibre light source is inserted transabdominally under local anaesthesia .An ultrasound scan is performed immediately prior to the technique so that damage to placenta and fetus is kept to the minimum.It can be performed in 18-20 weeks and the following samples can be obtained during the procedure Fetal liver biopsy [metabolic disorders ] Fetal skin biopsy [ skin disorders ]

Fetal Blood Sampling Cordocentsis ( percutaneous umbilical blood sampling )Direct access to the fetal circulation during the second and third trimesters is now possible through PUBS . It is the most widely used method for fetal blood sampling and transfusion PUBS is now the route of choice for intrauterine transfusion for severely anemic fetuses; it can start as early as 19 weeks

Indication for fetal blood samling

Fetal hemolytic disorder Fetal infection Acid-base balance - for fetal growth

restriction Karyotyping Suspected fetal thrombocytopenia Twin –twin transfusion syndrome Fetusl thyroid disorders Suspected fetal anaemia Abnormal Doppler flow Duodenal atresia Single umbilical artery Omphalocele

Risk: This invasive procedure may lead to abortion, preterm labour or preterm rupture of the membrane,fetal bradycardia,chrorioamniotics.

BIOPHYSICAL Ultrasonography Ultrasonography examination of the fetus in the early [10-14 week] pregnancy can detect the foetal anomalies. Detection rate is about 70-80% with the false positive rate of 5-6 %. The ultrasound is a sound wave beyond the audible range of frequency greater than 2MHz(cycle per second). SONAR stands for “sound,navigation,rating”. The clinical use was introduced by lan Donald in Glascow in 1958.It can be done TransvaginalTransabdominal

Magnetic resonance imaging(MRI)

It is the non invasive procedure that can be used for the fetal well being.An MRI (or magnetic resource imaging ) scan is a radiology technique that uses magnetism , radio waves, & a computer to produce images of body structures

Purpose

Fetal structure – CNS,thorax, abdomen,genitourinary tract, musculoskeletal tract & overall growth.Placenta – it position , density & evalucation of the trophoblastic diseases.Amniotic fluid quantityBiochemical , functional & metabolic malformation

Late pregnancyLate pregnancy

CLINICALCLINICAL

CLINICAL

The clinical assessment to done to assess the foetal growth.

It can be done by following methods:-Maternal weight gainBlood pressureAssessment of size of uterus & height of fundusClinical assessment of liquorEdema of feet Abdominal girth in last trimester

1.Maternal weight gain: 1.Maternal weight gain:

In second half of pregnancy: average weight gain is 1 kg/fortnight.

Excess weight gain: Could be 1st sign of pre-eclampsia.

If weight gain less than normal, stationary or falling: Look for IUGR

2. Blood pressure:

Initial recording of BP prior to 12 weeks helps to differentiate pre-existing chronic hypertension from pregnancy induced hypertension.

Hypertension, pre-existing or pregnancy induced may impair fetal growthh.

3. Assessment of size of uterus & height of fundus:

Top of fundus is measured from superior border of symphysis pubis (bladder should be empty) using a tape.

After 24 weeks of pregnancy, distance measured in cm normally corresponds to period of gestation in weeks

4.Clininical4.Clininical assessment ofassessment of liquorliquor

The normal range of aminiotic The normal range of aminiotic fluid volume (AFI) is wide but fluid volume (AFI) is wide but the approximate volumes are:the approximate volumes are: - 500 ml at 18 weeks- 500 ml at 18 weeks - 800 ml at 34 weeks.- 800 ml at 34 weeks. - 600 ml at term.- 600 ml at term.Clinical assessment is unreliable.Clinical assessment is unreliable.Objective assessment depends on USG Objective assessment depends on USG to measure:to measure: - deepest vertical pool (DVP).- deepest vertical pool (DVP). - Amniotic fluid - Amniotic fluid index (AFI). index (AFI).

BIOCHEMICALBIOCHEMICAL

BIOCHEMICAL

These test are mainly done for assessment of pulmonary maturity. 1. Shake test or Bubble test (Clement’s): Based on ability of pulmonary surfactant to form a foam or bubble on shaking which remains stable for at least 15 minutes. Increasing dilutions of amniotic fluid are mixed with 96 % ethanol, shaken for 15 seconds and inspected after 15 minutes for the presence of a complete ring of bubbles at the meniscus. Indicates maturity of the fetal lungs.

2. Foam Stability Index (FSI) :

Based on surfactant detection by shake test. Serial dilutions of amniotic fluid to quantitate amount of surfactant present. FSI >47 virtually excludes risk of RDS.

OTHER TEST3. Presence of phosphatidyl glycerol[PG]4. Saturated phosophatidly choline5. Amniotic fluid optical density 6. Florescence polarization

BIOPHYSICALBIOPHYSICAL

BIOPHYSICAL

It is the screening test for the utero-placental insufficiency . The fetal biophysical activities is initiated , modulated & regulated by the fetal nervous system . The fetal CNS is very much sensitive to diminished oxygenation.

Fetal Movement CountFetal Movement Count

1. Fetal movement monitoring1. Fetal movement monitoringCardif ‘count 10’ formulaCardif ‘count 10’ formula: :

Mother counts fetal movements starting at 9 am.Mother counts fetal movements starting at 9 am.Counting ends when 10 movements are perceived. Counting ends when 10 movements are perceived.

Report to physician if:Report to physician if:– (i) less than 10 movements occur during 12 hours on (i) less than 10 movements occur during 12 hours on

2 successive days or 2 successive days or – (ii) no movement is perceived even after 12 hours in a (ii) no movement is perceived even after 12 hours in a

single day.single day.

Daily fetal movement count (DFMC): Daily fetal movement count (DFMC):

One hour duration each in morning, noon and One hour duration each in morning, noon and evening. (Total 1+1+1 = 3 hours)evening. (Total 1+1+1 = 3 hours)Total counts multiplied by four gives daily (12 hour) Total counts multiplied by four gives daily (12 hour) fetal movement count (DFMC). fetal movement count (DFMC).

If there is diminution of number of ‘kicks’ to less than If there is diminution of number of ‘kicks’ to less than 10 in 12 hours (or less than 3 in each hour), it 10 in 12 hours (or less than 3 in each hour), it indicates fetal compromise.indicates fetal compromise.

Nonstress Testing(NST)

A test monitors the fetal heart rate in response to fetal movements in order to assess the integrity of fetal central nervous system & cardio vascular system.The non – stress test(NST) involves application of the fetal monitor to record the fetal heart rate. The mother is instructed to push a marker button when she feels the fetus move. The marker button when she feels the fetus move. The marker button indicates movement as it occurred in relationship to the fetal heart rate. With sufficient placental functioning ,the fetus should demonstrate an acceleration in heart rate with movement, in the same way that the adult experiences increased heart rate with exercises.

Purpose

To assess the fetal ability to cope with continuation of a high risk pregnancy.To determine the project ability of a fetus to withstand the stress of labour.To assess the fetal status in women for whom contraction stress test is contraindicated such as previous caesarean section,or preterm labour. 

IndicationsIndications

Indications(Maternal)Post dated Pregnancy Rh SenstizationMaterial age 35 or moreChronic renal diseaseHypertensionCollagen diseaseSickle cell diseaseDiabetesPremature rupture of membrancesHistory of still birthTrauma

Indications (Fetal)Decreased fetal movementsIntrauterine growth retardation(IUGR)Fetal evaluation after amniocentesisOligohydramnios/polyhydramnios

ResultReactive non stress test(normal/negative)Reactive indiacates a healthy fetus . The result requires two or more FHR accelerations of at least 15 beats per minutes , lasting at least 15 sec from the beginning of the acceleration to the end , in association to the end , in association with fetal movement during a 20 – minute period. Nonreactive nonstress test(abnormal)No acceleration or accelerations of less than 15 beats per min or lasting less than 15 sec in duration occur be interpretated because of the poor quality of the FHR tracing. 

3. Contraction stress TestsA contraction stress test is a test performed during pregnancy to verify whether or not the unborn baby’s heart is strong enough to withstand labour. It uses drugs or nipple stimulation to make the uterus temporarily contract in order to replicate labor contractions .The test is typically only used if the unborn baby has has abnormal results during other pregnancy health examinationsA contraction stress test(CST) can reveal whether your baby has an abnormal heart rate during contractions- a distinct pattern of slowing heartbeats during & immediately following a contraction-that may indicate distress .

CSTCST

Oxytocin drip started at 0.5 mU/min, double in Oxytocin drip started at 0.5 mU/min, double in every 15-20 min interval till 3 contractions lasting every 15-20 min interval till 3 contractions lasting for 40-60 sec occur in 10 minfor 40-60 sec occur in 10 min

Time taken 1½ - 2 hrsTime taken 1½ - 2 hrsNo hypoxia No hypoxia FHR pattern uncharged during FHR pattern uncharged during

contractioncontractionHypoxia Hypoxia FHR slows down with deceleration FHR slows down with deceleration

– Late deceleration is significant Late deceleration is significant

IndicationsIUGRPostmaturityHypertensive disorders of pregnancyDiabetes mellitusWomen with nonreactive NST 

ContraindicationsThird trimester bleedingIncompetent cervixMultiple gestationPrevious classical uterine incisionHistory of preterm labourPremature rupture of membranes.

Result:Negative contraction stress test (normal):A negative result is represented by late or variabal decelerations of the fetal rate.Positive result : is represented by late or variable declarations of the fetal heart with 50 % or more of the contractions in the absence of hyperstimulation of the uterus.Equivocal: An equivocal result contain decelerations but with less than 50% of the contractions ,or the uterine activity shows the hyperstimulation of the uterus. Unsatisfactory: An unsatisfactory result means that adequate uterine contractions cannot be achieved or the fetal heart rate tracing is not of sufficient quality for adequate intervention

 

5. FETAL CARDIOCOGRAPHY

It is a technical means of recording the fetal heartbeat & the uterine contractions during pregnancy,typically in the third trimester . The machine used to perform the monitoring is called a cardiotocography, more commonly known as an electronic fetal monitor(EFM) External measurement - means taping or strapping the two sensors to the abdomen measures the tension of the maternal abdominal wall – an indirect measure of the intrauterine pressure. Internal measurement- requires a certain degree of cervical dilatation , as it involves inserting a pressure catheter into the ulterine cavity , as well as attaching a scalp electrode to the fetal head to adequately measure the electric activity of the fetal heart to adequately measure the electric activity of the fetal heart

Effect on management : The use of cardiotography reduces the rate of seizures in the newborn , but there is no clear benefit in the prevention of cerebral palsy , perinatal death and other complication of labour . In contrast labour monitored by CTG is slightly more likely to result in instrumenet delivery ( forceps or vacuum extraction ) or caesarean section

5.The biophysical profile ( BPP ) :

Has 5 components 1. Fetal movement 2 .Fetal tone3 .Fetal breathing 4 .Amniotic fluid volume 5 .Fetal heart rate

Variable Variable Score – 2 Score – 2 Score – 0 Score – 0

Fetal reactivityFetal reactivity > 2 FHR > 2 FHR accelerationacceleration

No or < 2 No or < 2 accelerationacceleration

Fetal breathing Fetal breathing movementmovement

At least 1 of > 30 At least 1 of > 30 secsec No FBM or < 30 secNo FBM or < 30 sec

Fetal movement Fetal movement (Gross body (Gross body movement)movement)

> 3 discrete GBM> 3 discrete GBM < 2 or nil< 2 or nil

Fetal toneFetal toneAt least one episode At least one episode of limb flexion to of limb flexion to rapid extensionrapid extension

No limb movement or No limb movement or slow flexion slow flexion

Amniotic fluid volAmniotic fluid vol> 1 pocket of > 1 cm > 1 pocket of > 1 cm depth in two depth in two perpendicular planeperpendicular plane

Largest pocket < 1 Largest pocket < 1 cm in two cm in two perpendicular planes perpendicular planes

Interpretation Interpretation Score – 10 Score – 10 – Conservative management Conservative management – Repeat after 1 wk or after 3 days in IUGR, diabetes, Repeat after 1 wk or after 3 days in IUGR, diabetes,

postmaturitypostmaturityScore – 8 Score – 8 – Liqour normal, manage as beforeLiqour normal, manage as before– If less or postmaturity If less or postmaturity Deliver Deliver Score – 6 Score – 6 Equivocal Equivocal – Repeat test after 24 hrs Repeat test after 24 hrs – If same If same Deliver DeliverScore – 4 or less Score – 4 or less Abnormal Abnormal– Immediate delivery except when fetus is grossly immatureImmediate delivery except when fetus is grossly immatureModified BPS Modified BPS Placental grading consider Placental grading consider– If premature aging If premature aging Fetal compromise Fetal compromise

6.Fetal Monitering by Fetal Scalp Blood Sampling

Fetal Scalp blood sampling is done when CTG shows persistant abnormal trace.It is used in the high risk cases of delivery.Significance of fetal scalp blood PHNormal 7.25-7.35Border line 7.25-7.30Abnormal below 7.20 delivery is done for fetal asphyxia. 

Doppler Ultrasonography Doppler Ultrasonography

UterineUterineUmbilicalUmbilicalInternal carotid arteryInternal carotid arteryCerebral vesselsCerebral vesselsPeak systolic & end diastolic blood flow Peak systolic & end diastolic blood flow measuredmeasuredSystolic: Diastolic < 3 is normal in umbilical & Systolic: Diastolic < 3 is normal in umbilical & uterine arteryuterine arteryLack of diastolic component or reversal diastolic Lack of diastolic component or reversal diastolic blood flow is ominous sign.blood flow is ominous sign.

7. Amniocentesis in Late Pregnancy7. Amniocentesis in Late Pregnancy

Pulmonary maturityPulmonary maturityAssessment of severity of Rh-isoimmunisationAssessment of severity of Rh-isoimmunisationMaturity of fetus by Nile blue test Maturity of fetus by Nile blue test Orange cells > 50% mature fetusOrange cells > 50% mature fetus

8.Other test8.Other testAssessment of severity of Rh-isoimmunisation:

It is done by amniocentesis for estimation of bilirubin in the amniotic fluid by spectophometric analysis.Assesment of aminotic fluid leakage:

It can be done by fern test,nitrazine test,apt test.