Obstetrics and Gynecology
Hadeel Al Kayed
+962 795 049 775
Antepartum Fetal Surveillance
Antepartum fetal surveillance testing is typically performed in the third trimester (typically, at ≥ 32 weeks' gestation) to
assess fetal well-being and reduce the risk of adverse fetal outcomes.
Indications:
1. High-risk pregnancy (e.g., maternal medical conditions or fetal conditions associated with increased risk of fetal
hypoxic injury or death)
2. Perceived reduction in fetal movement by mother
Kick count - NST
Options include:
- Modified BPP
1. Kick counts Abnormal - Perform CST or BPP
NST or modified BPP
2. Nonstress test (NST)
3. Contraction stress test (CST) CST or BPP - Consider repeat testing or delivery
4. Biophysical profile (BPP)
5. Modified biophysical profile
6. Doppler studies
Before exploring antepartum fetal surveillance in detail, let's first understand how fetal heart rate (FHR) is assessed.
Almost all fetal surveillance tests rely on monitoring FHR to check the health of the fetus. This is an essential step in
ensuring the well-being of the baby during pregnancy.
FHR is typically designated as the baseline or basal heart rate and is normally 110–160 bpm.
Tachycardia
- Mild tachycardia: FHR of 160–180 bpm for > 10 minutes
- Severe tachycardia: FHR of ≥180 bpm for > 10 minutes
Causes: stress, hypotension, maternal fever, medication, chorioamnionitis, fetal arrhythmias, fetal anemia, hypoxia
Bradycardia
- Mild bradycardia: FHR of < 110 bpm for > 3 minutes
- Severe bradycardia: FHR of < 100 bpm for > 3 minutes
Causes: supine hypotensive syndrome, fetal heart defects, central nervous system anomalies, severe hypoxia.
Fetal heart rate variability
On CTG, variability of FHR is represented by the oscillation of the FHR around the baseline.
Type Oscillation amplitude Causes
Physiological fluctuation of FHR
Moderate variability 6–25 bpm
Normal finding
Absent variability Undetectable amplitude Severe fetal acidemia
Sleeping fetus
Minimal variability < 6 bpm Effects of opioids or magnesium
Fetal hypoxia
Fetal hypoxia
Marked variability > 25 bpm
Umbilical cord compression
5–15 bpm Severe fetal anemia
Sinusoidal variability
FHR wave resembles a sinus wave Severe fetal hypoxia
Accelerations
Description: a normal temporal increase in the FHR from the baseline by > 15 bpm for more than 15 seconds if the
gestational age is > 32 weeks, or by > 10 bpm for more than 10 seconds if the gestational age is < 32 week but less than
10 minutes.
Acceleration is the physiological reflection of fetal movement. If there is little (< 2 accelerations/ 20 minutes) or no
acceleration, this may be due to hypoxia, fetal immaturity, neurological or cardiac conditions, sedating medication;
however, it may also indicate that the fetus is asleep.
Decelerations
Description: a temporary decline in the FHR of > 15 bpm for a maximum duration of 2-3 minutes.
Type Etiology Characteristics
Early Compression of the head during a contraction The beginning and end of decelerations
deceleration triggering a vagal response. correspond with the progression of a contraction
(the deceleration reaches its minimum, referred to
as the nadir, when the contraction curve attains its
peak).
Late Uteroplacental insufficiency (leads to fetal Decrease in the FHR following the maximum
deceleration hypoxia and acidosis) contraction curve.
Variable Umbilical cord compression/prolapse Variable presentation and relation to the changes
deceleration in contractions.
Onset to nadir is abrupt (< 30 seconds) and lasts ≥
15 seconds but < 2 minutes.
Intermittent variable decelerations (< 50% of
contractions)
Recurrent variable decelerations (≥ 50% of
contractions)
Prolonged Continued uterine contractions, inferior vena A decrease in FHR of ≥ 15 bpm from the baseline,
deceleration cava syndrome, peridural anesthesia, rapid lasting ≥ 2 minutes but < 10 minutes
decrease in the mother's blood pressure
Reassuring and Non-Reassuring FHR Patterns
Non-Reassuring Patterns: Suggest that the fetus might be under stress or experiencing hypoxia. These patterns may
require intervention and include:
1. Fetal tachycardia (FHR > 160–180/min)
2. Fetal bradycardia (FHR < 110/min)
3. Loss of baseline variability
4. Recurrent variable decelerations and/or late decelerations
Reassuring Patterns: Indicate that the fetus is likely in a good condition. Reassuring patterns generally include:
1. Normal baseline FHR (110-160 beats per minute)
2. Moderate baseline variability (6-25 beats per minute)
3. Absence of concerning decelerations (like late or severe variable decelerations) or sinusoidal pattern
4. Presence of >2 accelerations within a 20 minute period (not as critical)
Fetal Surveillance Testing
Kick Count
Maternal counting of the number of fetal movements within a particular time period.
- No consensus on the optimal duration of monitoring or abnormal number of counts.
- Number of kicks reduced compared to prior assessments: Perform additional antepartum surveillance testing.
Nonstress test (NST):
NST is a noninvasive test that measures how fetal heart rate (FHR) responds to fetal movements; a rise in fetal heart
rate is expected with fetal movement.
It's a simple, non-invasive test and is often the first step in evaluating decreased fetal movements.
Method:
1. Perform electronic fetal heart rate monitoring over 20 minutes – 40 minutes.
2. Review the FHR tracing for FHR accelerations and decelerations.
Interpretation:
**Reactive nonstress test: a normal NST that shows ≥ 2 FHR accelerations over the course of 20 minutes.
Next step:
- If the indication for testing has resolved, offer reassurance; further testing is not required.
- If the indication persists, repeat the test (usually, weekly).
**Nonreactive nonstress test: an abnormal NST that shows < 2 FHR accelerations over the course of 20 minutes (after at
least 40 minutes of monitoring)
Causes of a nonreactive NST include:
1. Fetal sleep (most common)**
2. Hypoxemia or acidemia
3. Neurologic or cardiac abnormalities
4. Fetal immaturity ** (e.g., at 24–28 weeks' gestation)
5. Maternal drug use (e.g., sedatives)
Next step: Perform a BPP or CST.
Contraction stress test (CST)
CST is a test that measures how FHR responds to uterine contractions.
CST may induce early labor; thus, it should NOT be done if there are contraindications to labor or vaginal delivery (e.g.,
antepartum bleeding, placenta previa, PPROM). It's generally reserved for high-risk pregnancies or specific indications.
Method:
Perform cardiotocography to assess both FHR and uterine contractions over 20 minutes – 30 minutes.
If < 3 contractions lasting at least 40 seconds are observed over 10 minutes, induce contractions using either: Nipple
stimulation OR IV oxytocin.
Interpretation:
**Negative: absence of late decelerations or significant (recurrent, or profound) variable decelerations
Next step:
Resolution of indication for testing: Reassurance.
Persistence of the indication for testing: Consider weekly testing.
**Positive
Late decelerations after ≥ 50 % of contractions
Next step: Consider repeat testing (in 24 hours) or delivery.
**Equivocal
Defined as any of the following:
Intermittent variable decelerations or late decelerations (i.e., variable decelerations not occurring in more than half of
the contractions or late decelerations not occurring in more than half of the contractions as well)
Decelerations occurring with uterine tachysystole; This is when decelerations occur in a setting of frequent contractions,
more than five contractions in a 10-minute period, averaged over 30 minutes.
Next step: Repeat in 24 hours.
Biophysical profile (BPP)
The BPP is a noninvasive test consisting of fetal ultrasound of four specified parameters and NST.
Method
An ultrasound examination is performed over 30 minutes to Deepest Vertical Pocket (DVP):
assess the following four parameters: - Normal Range: Approximately 2 to 8 cm.
- Less than 2 cm is suggestive of oligohydramnios.
1. Fetal movement
- Greater than 8 cm is suggestive of
2. Fetal tone
polyhydramnios.
3. Fetal breathing
4. Amniotic fluid volume (deepest vertical pocket >> Amniotic Fluid Index (AFI):
amniotic fluid index) - Normal Range: Generally considered to be
5. An NST is then performed if any ultrasound parameter is between 5 and 24 cm.
abnormal but may be omitted if all are normal. - An AFI less than 5 cm indicates oligohydramnios.
- An AFI greater than 24-25 cm indicates
Each parameter of the ultrasound examination and the NST is
polyhydramnios
given a score of either 0 (abnormal/nonreactive) or 2
(normal/reactive)
Total Interpretation If Oligohydramnios Absent If Oligohydramnios Present
Score
≥8 Normal/ - Resolution of indication for testing: no further Gestational age ≥ 36 weeks: Delivery is
points reassuring testing indicated. often recommended.
- Persistence of the indication for testing: Gestational age < 36 weeks: Consider
Consider weekly testing. surveillance or delivery.
6 Equivocal - Consult obstetric specialist (either repeat BPP
points within 24 hours or delivery)
≤4 Abnormal - Consult obstetric specialist (Delivery is usually indicated; close monitoring may be
points performed if at < 32 weeks' gestation).
Modified biophysical profile
NST plus amniotic fluid measurement by ultrasound
Method: Use one of two methods (deepest vertical pocket of amniotic fluid OR amniotic fluid index) of assessing
amniotic fluid volume PLUS perform a NST
A normal result = a reactive NST plus either: deepest vertical pocket of amniotic fluid > 2 cm or amniotic fluid index of ≥
5 cm
An abnormal result = a nonreactive NST OR deepest vertical pocket of amniotic fluid ≤ 2 cm OR amniotic fluid index of < 5
cm
Next steps: For abnormal results, obtain a BPP or CST.
Doppler Ultrasound Studies
For suspected abnormalities in fetal/placental perfusion or suspected fetal deformities (e.g,. vascular abnormalities,
fetal masses, congenital heart disease).
Normally, the umbilical artery carries deoxygenated blood from the fetus to the placenta. The normal Doppler waveform
for the umbilical artery shows forward blood flow throughout the cardiac cycle, with a decrease in velocity during
diastole due to the resistance in the placental circulation. Reversed or inverted flow in the umbilical artery is an
abnormal condition characterized by the blood flow moving in the opposite direction, particularly during the diastolic
phase. This reversal indicates that the resistance in the placenta is so high that it impedes normal blood circulation from
the fetus to the placenta. This finding is a critical sign of severe placental insufficiency and is associated with a high risk
of adverse outcomes like IUGR, fetal hypoxia, and increased perinatal mortality.
The ductus venosus is a vital fetal blood vessel that directs oxygen-rich blood from the umbilical vein to the IVC,
bypassing the liver. Under normal conditions, the flow in the ductus venosus is forward, moving towards the heart.
Inverted flow in the ductus venosus is an abnormal finding where there is a reversal of the normal blood flow direction.
This abnormal flow pattern is most often observed during the atrial contraction phase of the cardiac cycle. Such a
reversal indicates significant fetal distress, often reflecting severe cardiac dysfunction. This finding is associated with a
high risk of serious adverse outcomes, including fetal heart failure, hydrops fetalis, and increased risk of perinatal
mortality, and thus requires immediate medical attention and intervention.
Vessel Pathological Finding Definition
Maternal High resistance flow A Doppler ultrasound finding where the blood flow in the uterine artery shows
Uterine increased resistance, typically characterized by a higher systolic to diastolic ratio. It
Artery indicates poor uterine artery remodeling (i.e., poor placentation).
Notching (early diastolic Presence of a notch or dip in the Doppler waveform during early diastole, reflecting
notch) turbulent blood flow in the uterine artery. It suggests abnormal blood flow possibly
due to inadequate trophoblastic invasion of the spiral arteries.
Umbilical Absent or reversed end- A condition where there is no flow (absent) or reverse flow (reversed) in the
Artery diastolic flow (ARED) umbilical artery during the diastolic phase of the cardiac cycle. It indicates increased
resistance to blood flow in the placenta.
High pulsatility index (PI) A measurement in Doppler ultrasound that indicates a high degree of variation in
blood flow velocity throughout the cardiac cycle, suggesting increased resistance to
blood flow in the placenta.
Fetal Middle Increased peak systolic This is a measure of the maximum blood flow velocity during systole in the middle
Cerebral velocity (PSV) cerebral artery. An increased PSV indicates higher than normal blood flow speed.
Artery Often a compensatory response to fetal anemia or hypoxia.
Decreased resistance A lower than normal pulsatility index in the fetal middle cerebral artery, indicating
(low PI) reduced resistance to blood flow. Often a compensatory response to fetal anemia or
hypoxia.
Ductus Absent or In the ductus venosus Doppler waveform, the absence or reversal of blood flow
Venosus reversed/inverted flow during the atrial contraction phase of the cardiac cycle. It often indicates
during atrial contraction compromised cardiac function or severe fetal hypoxemia.
(A-wave)
Altered pulsatility index A deviation from the normal range of pulsatility index in the ductus venosus,
reflecting atypical blood flow patterns.
1. Fetal biophysical profile involves assessment of all the following except:
A. CTG tracing
B. Ultrasound assessment of fetal breathing movements
C. Fetal Rapid eye movements
D. Fetal tone
E. Amniotic fluid volume
2. During the routine antenatal visits, a pregnant lady in her 36 weeks gestation recorded a decrease in the fetal
activity. The proper next step should be….
A. Order for contraction stress test
B. Offer her biophysical profile
C. Perform vaginal examination to assess the situation for immediate delivery
D. Ask for a NST
E. Check the rate and the rhythm of fetal heart rate by the ultrasound
3. During the routine antenatal care for a primigravida at 34 weeks gestation of, all the following tests could be
applied for proper assessment and followed by proper action except …
A. Non stress test
B. Contraction stress test
C. Biophysical profile
D. Kick counts test
E. Ultrasound sonography
4. A 37-year-old, G4P2, presents to your office for new OB visit at 8 weeks. In a prior pregnancy, the fetus had
multiple congenital anomalies consistent with trisomy 18, and the baby died shortly after birth. The mother is
worried that the current pregnancy will end the same way, and she wants testing performed to see whether this
baby is affected. Which of the following can be used for chromosome analysis of the fetus?
A. Biophysical profile
B. Chorionic villus sampling
C. Fetal umbilical Doppler velocimetry
D. Maternal serum screen
E. Nuchal translucency
1 C
2 D
3 B
4 B
