Objective of Antenatal care and
screening of high risk
pregnancy
- DR . RUPSHA
CHOWDHURY
MS,DNB( OBSTETRICS AND
GYNAECOLOGY )
ASSISTANT PROFESSOR
SRIMS AND SANAKA
HOSPITAL
Definition of 'Antenatal Care'
It is the periodical and regular supervision
and care of pregnant women to prevent
and/ or detect any abnormality at the
earliest possible time , the primary aim of
which is to achieve a healthy mother and
healthy baby at the end of pregnancy.
The primary objective of antenatal fetal assessment is to
avoid fetal death and deliver a healthy baby at the end
of pregnancy/or best possible time
As such simultaneously with good maternal care during
pregnancy and labor, the fetal health in utero
should be supervised with equal vigilance.
Aims of antenatal fetal monitoring:
1.To ensure satisfactory growth and well-being of the
fetus throughout pregnancy.
2.To screen out the high-risk factors that affect the growth of
the fetus.
Rationality of Antenatal Fetal Tests
Tests must provide information superior to that of
clinical evaluation
Test results should be helpful in management to
improve perinatal outcome
Benefits of tests must outweigh the potential risks
and the costs
INVERTED PYRAMID OF ANTENATAL
CARE
Traditional approach-
NICE-Every 4 weeks till 28 th week, then at an
interval of 2 weeks upto 36 th week and then weekly
till delivery in an otherwise uncomplicated
pregnancy (10 check up in primi)
WHO- Total 8 contacts or more- 1st upto 12
weeks, 2nd at 20 weeks, 3rd at 26 th, 4th at 30th, 5
th at 34th, 6 th at 36th, 7th at 38 weeks and 8 th at
40 th.To return at 41 weeks if not given birth.
Inverted pyramid-
Following initial assessment at 11 to 13 weeks
pregnancy women are classified as low risk and
high risk.The number of minimal visits in low risk
group can be minimised to 3 or 4 visits.Second
visit can be done at 19-20 weeks for foetal
anomaly scan and assessment of growth and
risk factors for complications like pre eclampsia
and preterm delivery.Third visit is scheduled at
37 weeks and she may return at 41 weeks if
undelivered.
Prenatal genetic counseling(early pregnancy)-
Detection and identification of couples who are at high
risk of having a child with inherited(chromosomal or
genetic) disorder.
Methods-
Chorionic villus sampling
Amniocentesis
Cordocentesis
Foetal cells from maternal blood
Free foetal DNA
USG
Foetal echocardiography
First trimester- biophysical-nuchal translucency
and nasal bone.biochemical-free bhCG and PAPPA
Integrated test(11-13+6 weeks)(NT, PAPPA and
hcg)
Second trimester screening-
Triple test(15-22 weeks) -MSAFP, hCG,uE3
Quadruple marker- MSAFP,uE3,MSAFP,inhibin A
Anomaly scan(18-21weeks)
Best screening is combined first and second
trimester procedure(ACOG)
Chorionic villi sampling-
transcervically between 10 and 13 weeks and
transabdominally from 10 weeks to term
Procedure-a few villi collected from chorion
frondosum under ultrasonic guidance
Complications -fetal loss, oro mandibular and limb
deformities or vaginal bleeding
Amniocentesis -
Performed after 15 weeks using ultrasonographic
guidance
Cordocentesis -
Performed from 18 weeks gestation.Umbilical vein is
preferred
ANTEPARTUM FETAL SURVEILLANCE (LATE PREGNANCY)
OBJECTIVES ARE (ACOG)—(1) Prevention of fetal death and (2) avoidance of
unnecessary interventions.
1. Biophysical 2.Biochemical 3.Clinical METHODS:
CLINICAL: The clinical assessment of fetal growth can be evaluated by the SFH. They
may be useful as screening test for further investigation.
BIOCHEMICAL: Biochemical tests are mainly done for assessment of pulmonary
maturity .
BIOPHYSICAL: Principle—Biophysical profile is a screening test for utero–placental
insufficiency.
The fetal biophysical activities are initiated, modulated and regulated through fetal
nervous system.
The fetal CNS is very much sensitive to diminished oxygenation. Hypoxia o metabolic
acidosis o CNS depression o changes in fetal biophysical activity
1.Fetal movement count—Any of the two methods can be
applied:
1.Cardif “count 10” formula: “a patient counts fetal movements starting at 9 am.“a
counting comes to an end as soon as 10 movements are perceived. She is instructed
to report the physicianif—
(i) less than 10 movements occur during 12 hours on 2 successive days or
(ii) no movement is perceived even after 12 hours in a single day.
2.Daily fetal movement count (DFMC): “three counts each of 1 hour duration
(morning, noon and evening) are recommended. “a total counts multiplied by four
gives daily (12 hour) fetal movement count (DFMC).
If there is diminution of the number of “kicks” to less than 10 in
12 hours (or less than 3 in each hour), it indicates fetal compromise.
Mothers perceive 88% of the fetal movements detected by Doppler imaging.
the count should be performed daily starting at 28 weeks of pregnancy.
Loss of fetal movements is commonly followed by disappearance of
FHR within next 24 hours.
In either of the earlier methods, if the result is ominous, the candidate is
subjected to NST.
Maternal hypoglycemia is associated with increased fetal movements.
Maternal perception of fetal movements may be reduced with fetal
sleep (quiet), fetal anomalies (CNS), anterior placenta, hydramnios,
obesity, drugs (narcotics), chronic smoking and hypoxia.
2.Non-stress test (NST): In non-stress test, a continuous electronic monitoring of
the fetal heart rate along with recording of fetal movements (cardiotocography) is
undertaken.
There is an observed association of FHR acceleration with fetal movements, which
when present, indicates a healthy fetus.
It can reliably be used as a screening test.
The accelerations of the FHR associated with fetal movements are presumably reflex
mediated.
It should be emphasized that the test is valuable to identify the fetal wellness
rather than illness.
The following biophysical tests are used:
(1) Fetal movement count
(2) Ultrasonography
(3) Cardiotocography
(4) Non-stress test (NST)
(5) Fetal biophysical profile (BPP)
(6) Doppler ultrasound
(7) Vibroacoustic stimulation test
(8) Contraction stress test (CST)
(9) Amniotic fluid volume
Interpretation:
Reactive (Reassuring)—When two or more accelerations of more than 15 beats per
minute above the baseline and longer than 15 seconds in duration are present in a 20
minute observation.
Non-reactive (Non-reassuring)—Absence of any fetal reactivity.
A reactive NST is associated with perinatal death of about 5 per 1,000. But perinatal
death is about 40 per 1,000 when the NST is nonreactive.
Testing should be started after 30 weeks and frequency should be twice weekly.
The test has a false negative rate of 0.5% and false positive rate of 50%
3.Vibroacoustic stimulation (VAS) is used to change the fetal sleep state from quiet
(non-REM) to active (REM) sleep.
A reactive NST after VAS indicates a reactive fetus. The procedure
is harmless.
4.Fetal Biophysical Profile (BPP)—considers several parameters .
BPP using real time ultrasonography has a high predictive value
Indications
1—Non-reactive NST,
2. high-risk pregnancy.
Test frequency
weekly after a normal NST,
twice weekly after an abnormal test.
Modified Biophysical Profile consists of NST and ultrasonographically determined
amniotic fluid index (AFI).
Modified BPP is considered abnormal (nonreassuring) when the NST is non-reactive
and/or the AFI is < 5.
An abnormal score of 4 or less is associated with fetal acidemia.
Abnormal BPP is associated with high risks of stillbirth and perinatal
mortality.
5.Fetal Cardiotocography (CTG):
A normal tracing after 32 weeks, would show baseline heart rate of
110–160 beats per minute (bpm) with an amplitude of baseline variability 5–25 bpm.
There should be no deceleration or there may be early deceleration of very short
duration.
Importantly, there should be two or more accelerations during a 20-minute period
6.Ultrasonography:
IUGR can be diagnosed accurately with serial measurement of BPD, AC, HC, FL
and amniotic fluid volume.
AC is the single measurement which best reflects fetal nutrition.
The average increase of biparietal diameter beyond 34 weeks is 1.7 mm per week.
When the HC/AC ratio is elevated (> 1.0) after 34 weeks, IUGR is suspected .
Ultrasound examination is the main diagnostic tool to assess fetal growth
7.Amniotic fluid volume (AFV):
Amniotic fluid volume is primarily dependent upon the fetal urine
output, pulmonary fluid production and fetal swallowing.
Decreasing AFV may be the result of fetal hypoxia and placental insufficiency.
A vertical pocket of amniotic fluid > 2 cm is considered normal.
Amniotic fluid index (AFI) is the sum of vertical pockets from four quadrant of uterine
cavity.
AFI < 5 is associated with increased risk of perinatal mortality and morbidity
8.Doppler Ultrasound Velocimetry:
Doppler flow velocity waveforms are obtained from arterial and venous beds in the
fetus .
Arterial Doppler (umbilical artery) waveforms are helpful to assess the downstream
vascular resistance.
The arterial Doppler waveform is used to measure the peak systolic (S), peak diastolic
(D)and mean (M) volumes. From these values S/D ratio, pulsatility index (PI) [PI = (S–
D)/M] or resistance index (RI) [RI = (S–D)/S] are calculated
In a normal pregnancy the S/D ratio, PI and RI decreases as the gestational age
advances.
Higher values greater than 2 SDs above the gestational age mean indicate reduced
diastolic velocities and increased placental vascular resistance. These features are at
increased risk for adverse pregnancy outcome.
Venous Doppler (Ductus Venosus, Umbilical Vein) parameters provide information
about cardiac forward function (cardiac compliance, contractility and after-load).
Fetuses with abnormal cardiac function show pulsatile flow in the umbilical vein (UV).
Normal UV flow is monophasic
The fetuses having UA Doppler flow abnormalities (AEDV or REDV) are at higher risk
of intrauterine hypoxia.
Risk of stillbirth is high when the Doppler flow in the ductus venosus (venous
parameter) is abnormal.
Use of ultrasonography for fetal biometry and Doppler study for umbilical artery flow
velocimetry has reduced perinatal mortality and unnecessary early intervention
significantly.
9.Contraction stress test (CST) is based to observe the response of the fetus at risk
for uteroplacental insufficiency in relation to uterine contractions
OTHER INVESTIGATIONS IN LATE PREGNANCY
Amniocentesis in late pregnancy:
1.Assessment of severity of Rh iso-immunization2.Test for fetal pulmonary maturity
Pulmonary maturity: Confirmation of lung maturation reduces the incidence of respiratory
distress syndrome (RDS) in the newborn. The risk of RDS is high for infants that are delivered
preterm (< 37 weeks).
RDS is caused by the deficiency of pulmonary surfactant, which is synthesized by the type II
alveolar cells. Surfactant is packaged in lamellar bodies o discharged in the lung alveoli
2.Assessment of severity of Rh–isoimmunization is done by amniocentesis for
estimation of bilirubin in the amniotic fluid by spectrophotometric analysis.
The optical density difference at 450 nm gives the prediction of the severity of fetal
hemolysis
High risk pregnancy
Pregnancy where the mother or fetus
has an increased risk of adverse
outcomes compared to uncomplicated
pregnancies.
Pre pregnancy risk factors-
Chronic hypertension
Diabetes mellitus
Epilepsy
Haemoglobinopathy
Bad obstetric history
Chronic kidney disease
History of infertility
Extremes of age
High risk factors in previous pregnancy
History of uterine surgery/ C section
Heart disease
Thyroid disorder
Malignancy eg cervical or ovarian or breast cancer
Uterine anomalies
Uterine fibroid
Obese/ malnourished
Risk factors during pregnancy
Multifoetal gestation
Rh negative pregnancy
Anaemia/ bleeding disorders
Antepartum haemorrhage
Malposition or malpresentation
Foetal growth restriction
IUFD
Jaundice
Obstetric cholestasis
Problem with amniotic fluid
Premature rupture of membrane
Pregnancy induced hypertension
Gestational diabetes mellitus
Foetal risk factors-
Foetal growth restriction
Hydrocephalus
Foetal anomalies eg heart defects
Macrosomia
