Antepartum fetal surveillance

are now routinely used to identify high risk fetuses in pregnancies complicated by preexisting
maternal conditions (eg, diabetes mellitus) as well as pregnancy complications (eg, intrauterine
growth restriction). An abnormal test is a warning sign, while normal tests are reassuring since fetal
deaths within 1 week of normal test are rare. Indeed, the negative predictive values (true negative
test) for most of the tests are 99.8% or higher. In contrast, the positive predictive values (true
positive tests) for abnormal results are quite low (10–40%).

Different Antepartum fetal surveillance techniques

Fetal movement assessment (“kick counts”)

A reduction in the maternal perception of fetal movement often but not invariably
precedes fetal death, in some cases by several days.

The woman lies on her side and counts fetal movements. Perception of 5 distinct
movements in a period of up to 1 hour is considered reassuring. If 5 movements have been felt
within half an hour, the kick count may end. In the absence of a reassuring count, further fetal
assessment is recommended.

Nonstress test (NST)

The NST is based on the premise that the heart rate of the fetus will temporarily
accelerate with fetal movement. Heart rate reactivity is a good indicator of normal fetal
function. Loss of reactivity is associated most commonly with fetal sleep but may result from
central nervous system depression, including fetal acidosis.

With the patient in the lateral tilt position, the fetal heart rate is monitored. In fetal heart
rate accelerations the peak is at least 15 beats per minute above the baseline and last 15 seconds.

Acoustic stimulation of the fetus may elicit heart rate accelerations.

A reactive (normal) NST has >2 fetal heart rate accelerations (as defined previously)
within a 20-minute period, with or without fetal movement.

A nonreactive NST lacks sufficient fetal heart rate accelerations over a 40-minute
period.

The NST of the normal preterm fetus is frequently nonreactive:

 24-28 gest. week: up to 50% are nonreactive,

28-32 gest.week: up to 15% are non reactive.

Variable decelerations (spikes) may be observed in up to 50% of NSTs.

 If non repetitive and brief (<30 seconds), they indicate neither fetal
compromise nor the need for obstetric intervention.

 Repetitive variable decelerations (at least 3 in 20 minutes), even if mild, are

associated with an increased risk of cesarean delivery.

 Decelerations that persist for >1 minute (prolonged decelerations) are

associated with a markedly increased risk of both cesarean delivery for a
nonreassuring fetal heart rate pattern and fetal demise.

Biophysical profile (BPP)

The BPP consists of NST combined with four observations made by ultrasonography.

 Nonstress test (which, if all four ultrasound components are normal, may be
omitted without compromising the validity of the test results).

 Fetal breathing movements (≥1 episodes of rhythmic fetal breathing

movements of >30 seconds within 30 minutes).

 Fetal movement (>3 discrete body or limb movements within 30 minutes).

 Fetal tonus (>1 episodes of extension of a fetal extremity with return to

flexion, or opening or closing of a hand).

 Amniotic fluid volume (amniotic fluid index (AFI) >5 cm or a single vertical
pocket of amniotic fluid >2 cm is adequate amniotic fluid).

Each of the five components is assigned a score of either 2 (normal or present see
above) or 0 (abnormal, absent, or insufficient). A total score of 8 or 10 is normal, a score of 6
is considered equivocal, and a score of 4 or less is abnormal. Regardless of the score, if
oligohydramnios (AFI <5 cm or a largest vertical pocket of amniotic fluid 2 cm), further
evaluation is warranted.

Modified biophysical profile

It combines the NST with the amniotic fluid index (AFI), which is the sum of
measurements of the deepest cord-free amniotic fluid pocket in each of the abdominal
quadrants.

Normal modified BPP: reactive NST, AFI >5,

Abnormal: nonreactive NST, AFI <5

Umbilical artery Doppler velocimetry

 It is based on the observation that flow velocity waveforms in the umbilical

artery of normally growing fetuses differ from those of growth-restricted
fetuses. The umbilical flow velocity waveform of normally growing fetuses is
characterized by high-velocity diastolic flow, whereas with intrauterine growth
restriction, there is diminution of umbilical artery diastolic flow.

 No benefit has been demonstrated for umbilical artery velocimetry for

conditions other than suspected intrauterine growth restriction, such as postterm
gestation, diabetes mellitus, systemic lupus erythematosus, or antiphospholipid
syndrome.

 Doppler ultrasonography has not been shown to be of value as a screening test

for detecting fetal compromise in the general obstetric population.

Clinical considerations and recommendations

Indications for antepartum fetal surveillance

Maternal conditions

 Diabetes mellitus.

 Hypertensive disorders.
  Hyperthyroidism (poorly controlled).

 Heart disease.

 Hemoglobinopathies.

 Chronical renal disease.

 Systemic lupus erythematosus.

 Antiphospholipid syndrome.

Pregnancy-related conditions

 Pregnancy-induced hypertension.

 Reduced fetal movement.

 Oligohydramnios.

 Polyhydramnios.

 Intrauterine growth restriction.

 Postterm pregnancy.

 Isoimmunization (moderate to severe).

 Previous fetal demise (unexplained or recurrent risk).

 Multiple gestation (with significant growth discrepancy).

Initiation of antepartum fetal surveillance

For most at-risk patients initiation of antepartum fetal surveillance at 32-34 weeks
of gestation is appropriate. However, in pregnancies with multiple or particularly worrisome
high-risk conditions (eg, chronic hypertension with suspected intrauterine growth restriction),
testing might begin as early as 26-28 weeks of gestation.
Frequency of testing

If the maternal medical condition is stable, tests of fetal well-being (NST, BPP, or
modified BPP) are repeated at weekly intervals, but in the presence of certain high-risk
conditions, such as postterm pregnancy, type 1 diabetes, intrauterine growth restriction, or
pregnancy-induced hypertension, testing are performed two-three times a week or daily.

Management of abnormal results

Pregnancies with decreased fetal movement should be evaluated by an NST, BPP, or

modified BPP.

 Normal tests exclude imminent fetal jeopardy.

 A nonreactive NST or an abnormal modified BPP is indication for additional

testing (full BPP and/or Doppler velocimetry).

 A BPP score of 6 is considered equivocal:

 term fetus - prompt delivery,

 preterm fetus - repeat BPP in 24 hours.

- Administer maternal corticosteroid in pregnancies < 34 gest. weeks

 Repeated equivocal scores should result in either delivery or continued

intensive surveillance. A BPP score of 4 usually indicates that delivery is
warranted.

In case of growth-restricted fetuses: Use umbilical artery Doppler as the primary

surveillance tool

 When an anomaly scan and umbilical artery Doppler are normal, the small fetus
is likely to be a ‘normal small fetus’. Outpatient management is safe.

 Abnormal flow velocity waveforms are correlated with fetal hypoxia and
acidosis and increased perinatal morbidity and mortality.
 When end diastolic flow is absent or reversed, admission, close surveillance
and administration of steroids are required.

 If other surveillance results (biophysical profile, cerebral blood flow) are

abnormal, delivery is indicated