ASSESSMENT OF FETAL

WELLBEING
BIOPHYSICAL

BIOCHEMICAL
• Maternal serum alfa feto protein

(MSAFP)

• Triple test

• Acetyl choline esterase (AChE)

• Inhibin A

• Amniocentesis

• Chorionic villus sampling (CVS)

• Cordocentesis
 • Fetal movement count

• Cardiotocography (CTG)

• Non stress test (NST)

BIOPHYSICAL • Fetal biophysical profile (BPP)

• Doppler ultrasound

• Vibroacoustic stimulation test

• Contraction stress test (CST)

 MATERNAL SERUM ALFA FETO PROTEIN (MSAFP)
• Analysed at 15 to 20 weeks' gestation to identify certain birth
defects and chromosomal abnormalities during pregnancy.
Elevated in : Decreased in

Open neural tube defects Trisomy 21

Open abdominal defects Gestational trophoblastic disease

Congenital nephrosis

Rh isoimmunization

Multiple gestation

Maternal diabetes mellitus

Fetoplacental dysfunction.
 TRIPLE TEST

• Includes MSAFP, hCG & UE3.

• Performed at 15 – 18 wks of gestation

• Trisomy 21: decreased MSAFP & UE3, increased hCG

• Trisomy 18 (Edwards syndrome) : decreased MSAFP, UE3, &

hCG
 Acetyl choline esterase (AChE)

• Amniotic fluid AChE levels are elevated in open NTDs

 Inhibin A

• Is a dimeric glycoprotein.

• Produced by the corpus leuteum & placenta.

• Trisomy 21 : increased level of serum inhibin A

 Amniocentesis
• Amniocentesis is a procedure in which amniotic fluid is removed
from the uterine cavity by insertion of a needle through the
abdominal and uterine walls and into the amniotic sac.
 Cytogenic analysis- the desquamated cells from the amniotic fluid

are cultured and examined for diagnosis of trisomy 21 (Down’s

syndrome), monosomy x (turners syndrome) and others.

 DNA analysis- single gene disorders (cystic fibrosis, tay-sac

disease) can be diagnosed using DNA probes from the amniotic

fluid.

 Acetyl Choline Esterase – level is elevated in most cases of open

nueral tube defects. It has got better diagnosis than AFP

 In determination of lung maturity, the

lecithin/sphingomyelin (L/S) ratio of the amniotic fluid is

analyzed.

 When the L/S ratio is 2:1 or greater, the fetal lung is

considered mature and the incidence of respiratory distress

syndrome in the newborn is low.

 Results may be less reliable with maternal diabetes or if

the fluid is contaminated with blood or meconium.

 The presence of phosphatidylglycerol (PG), one of the last lung

surfactants to develop, is the most reliable indicator of fetal lung

maturity. PG is not present until 36 weeks' gestation and is

measured as being present or absent.

 Chorionic villus sampling (CVS)

• CVS involves obtaining samples of chorionic villus (placental

tissue [fetal origin]) to test for genetic disorders of the fetus.

• CVS is performed between 8 and 12 weeks' gestation.

• Using an ultrasound picture, a catheter is passed vaginally or

abdominally into the woman's uterus, where a sample of

chorionic villus tissue is snipped off or obtained by suction (10-

40mg).
Results from CVS are reported at 2 stages.

 The 1st result is available by 24-48 hours and gives a chromosome

count (Down’s syndrome).

 Cells are then cultured for 14-24 days for detailed cytogenic

examination of the chromosome structure.

Complications :
 rupture of membranes

 intrauterine infection

 spontaneous abortion

 hematoma

 foetal trauma

 maternal tissue contamination

 If performed before 8 weeks limb reduction defects can occur.

 Cordocentesis

• PUBS (percutaneous umbilical blood sampling) involves a

puncture of the umbilical cord for aspiration of fetal blood under

ultrasound guidance after 18 weeks gestation.

• Using ultrasound picture, the provider inserts a needle for

insertion into one of the umbilical vessels 1-2 cm from the placental

insertion. A small amount of blood (0.5-2ml) is withdrawn.

 It is used in the diagnosis of fetal blood disorders, infections,

Rh isoimmunization, metabolic disorders, and karyotyping.

 Can also be used for fetal therapies, such as RBC and platelet

transfusion.
 Fetal movement count

• Cardiff Count-to-Ten:

o Assess fetal movement once per day at the same time each day. I.e.

the woman starts to count the fetal movements at same time and

stops as soon as she perceived 10 movements.

o Less than 10 fetal movements in 10-12 hours for 2 consecutive days

or no fetal movement in a 10-hour period must be reported to the

primary care provider.

• Sadovsky / Daily fetal movement count (DFMC):

o Assess fetal movement three times each of one hour every day

(morning, noon, evening) at the same time.

o Total count multiplied by 4 gives daily (12hrs) fetal movement

count.

o Less than 3 fetal movements in each hour or less than 10 in 12

hrs must be reported to the primary care provider.

 Cardiotocography (CTG)

• After 32 wks base line fetal heart rate

: 110 – 160 bpm

• Base line variability : 5-25 bpm

• No deceleration or there may be early

deceleration.

• 2 or more acceleration in 20 minute

period
 Non stress test (NST)

• The nonstress test (NST) is used to evaluate FHR accelerations

that normally occur in response to fetal activity

• Accelerations are indicative of an intact central and autonomic

nervous system and are a sign of fetal well-being.

• Absence of FHR accelerations in response to fetal movements

may be associated with hypoxia, acidosis, drugs (analgesics,

barbiturates), fetal sleep, and some fetal anomalies.

Interpretation:

• Reactive: 2 or more accelerations of more than 15 bpm above

the baseline lasting for more than 15 sec in duration in a 20 min

observation.

• Non – reactive : absence of any fetal reactivity.

 Fetal biophysical profile (BPP)
• The BPP uses ultrasonography and NST to assess five
biophysical variables in determining fetal well-being. A BPP is
performed during a 30-minute time frame.
 Total score- 10. Normal score for each-2. Abnormal score for each-0

Parameters Minimal normal criteria Score

Nonstress test Reactive pattern 2

Fetal breathing movement 1 episode lasting >30 sec. 2

Gross fetal body movements Three or more body or limb movements, to include 2
rolling, in 30 minutes.

Fetal muscle tone One or more episodes of active extension with 2

return to flexion of spine, hand, or limbs.

Amniotic fluid index volume 1 pocket measuring 2cm or more in two 2

perpendicular plane.
BPP SCORE INTERPRETATION MANAGEMENT

8 – 10 No fetal asphyxia Repeat testing at weekly interval

6 Chronic asphyxia If >36 wks deliver

4 Chronic asphyxia If ≥ 36 wks deliver, if < 32 wks

repeat testing in 4 – 6 hours

0-2 Certain asphyxia Test for 120 min persistent

score ≤ 4 deliver regardless of
gestational age.
 Doppler ultrasound

• Ultrasound is a non-invasive, safe technique that uses reflected

sound waves as they travel in tissue to produce a picture.

• Used to diagnose fetal anomalies, BPD, HC, AC, AFI, doppler

velocimetry of umbilical artery & vein & for other diagnostic

studies.
 Vibroacoustic stimulation test

• Vibroacoustic stimulation (sound plus vibration), involve the use

of handheld battery-operated devices (usually a laryngeal stimulator)

placed over the mother's abdomen near the fetal head.

• This technique produces a low-frequency vibration and a buzzing

tone intended to induce fetal movement along with associated FHR

accelerations. The sound stimulus lasts for 2 to 5 seconds. The

vibroacoustic stimulation test (VST) are used to change the fetal

sleep from quiet non- REM to active REM sleep.

• If no FHR accelerations occur in response to the stimulus, it is

repeated at 1-minute intervals up to three times. If the FHR pattern

remains nonreactive, further evaluation with BPP or CST is

indicated.
 Contraction stress test (CST)

• This test is used to evaluate the ability of the fetus to withstand

the stress of uterine contractions as would occur during labour.

• Interpretation of CST/OCT
 Negative (normal): no late decelerations or significant
variable decelerations.
 Positive (abnormal): persistent late decelerations of FHR or
late decelerations with > 50% of uterine contractions.
 Suspicious: inconsistent but definite late decelerations do
not persist with most uterine contractions.
 Unsatisfactory: quality of tracing inadequate to assess or
adequate contractions not achieved
 Hyperstimulation: deceleration of the FHR with
contractions lasting > 90 seconds or occurring more
frequently than every 2 minutes