6/16/2017 Disclosures • I have nothing to disclose Antenatal Testing: Who, When, How? Brian L. Shaffer, MD Associate Professor Maternal Fetal Medicine Doernbecher Fetal Therapy June 15, 2017 FM: Rationale Objectives: Fetal monitoring - Who, When, How (What)? • Prevent Stillbirth • Rationale/Background for Fetal Monitoring (FM) • Physiology • Who? - Risk for IUFD – Hypoxemia & Acidemia � Observe fetal behavior changes – Risk: Cause v. Association • Fetal heart rate pattern – Cesarean: APA/Fetal indications? • Fetal activity, tone • ↓ Fetal renal perfusion � ↓ Amniotic fluid • When? Modifiers, Disruptors and Confounders – Gestational age, Risk factors, clinical scenario – Maternal medications, Fetal abnormalities (genetic, • How (What)? infectious, structural), Fetal sleep-wake cycles, GA, etc. – Fetal movement � Doppler • Can all lead to False alarms (False positives) – Test performance 1
6/16/2017 FM: Rationale - Prevent Stillbirth FM: Iceland – ~1/1000 • US Stillbirth (≥20 weeks): ~6/1000 (2013) • US Stillbirth (≥20 weeks): ~6/1000 (2013) • ~3/1000 (≥28 weeks) • ~3/1000 (≥28 weeks) – Rate ↑ 38 weeks – Rate ↑ 38 weeks – Need indication <39 wks – Need indication <39 wks • Ideally, FM would: • Ideally, FM would: – Identify those at ↑ risk – Identify those at ↑ risk – Excellent test characteristics – Excellent test characteristics • Highly sensitive • Highly sensitive • Few false positives • Few false positives – Goal: 2/1000 – Goal: 2/1000 Smith GCS, AJOG 2005 Smith GCS, AJOG 2005 Of the following interventions, which is FM: Rationale proven to prevent stillbirth? • Promote vaginal delivery/prevent CD? – Placenta � “shelf life” 96% A. Low dose Aspirin – Passenger � grows – Pelvis � static B. Low molecular weight heparin • NTSV CD 25.8% (2015) C. Phosphodiesterase inhibitors – 38 wks: 22% D. Delivery – 40 wks: 25% 3% 0% 0% – Post term: 35% • No data to support his notion • Few data to support FM Barber et. al., Obstet Gynecol 2011 2
6/16/2017 Of the following interventions, which is proven to prevent stillbirth? 1. Low dose Aspirin – 14% � in stillbirth/neonatal death 2. Low molecular weight heparin – APA? 3. Phosphodiesterase inhibitors - Early onset IUGR? 4. Delivery – Must balance GA vs. Risk of Stillbirth + FM: May lead to interventions/delivery - Caution Of the following interventions, which is proven to prevent • Must accept downstream possibilities stillbirth? – Abnormal test may be true or false positive • Abnormal test may lead to additional testing 1. Low dose Aspirin – 14% � in stillbirth/neonatal death • May lead to maternal anxiety • Birth plan 2. Low molecular weight heparin – APA? • Not preferred or 3. Phosphodiesterase inhibitors - Early onset IUGR? not acceptable to some 4. Delivery – Must balance GA vs. Risk of Stillbirth 3
6/16/2017 FM: May lead to interventions/delivery - Caution Fetal Monitoring: Who? • Traditionally – those at increased risk for stillbirth • May lead to recommendation for Delivery (IOL) • Stillbirth causes/contributing factors: numerous – IOL - Side effects/Risks • Oxytocin: Tachysystole, Hyponatremia – Risk factor (e.g., AMA or prior cesarean) ≠ Cause – Oxytocin not likely to be associated with Autism, Cesarean • Demo: Black, ↓ Education, ↓SES, ↑ Maternal age • Prostaglandins - Fever, nausea & vomiting • Medical: Diabetes, Hypertension, Renal, Lupus, Cardiac • Uterine rupture (e.g., TOLAC) • Amniotic fluid embolism (~5/100,000) • Modifiable Risk (potentially): Obesity, substance use, etc. – If indicated, outcomes are generally improved • Clinical Risk: prior IUFD, prior abruption, multiples, short interval pregnancy, SGA, biomarkers • Unexplained – 25-60% Of the following maternal risk factors, which has Of the following maternal risk factors, which has the the highest adjusted odds ratio for stillbirth? highest adjusted odds ratio for stillbirth? OR 95% CI 56% A. Multiple pregnancy A. Multiple pregnancy 4.59 2.63-8.0 B. Diabetes B. Diabetes 2.50 1.39-4.48 C. Prior Stillbirth C. Prior Stillbirth 5.91 3.18-11.0 D. Smoking D. Smoking 1.55 1.02-2.35 E. AMA ≥ 40 12% 11% 10% E. AMA ≥ 40 2.41 1.24-4.70 6% 5% F. Drug addiction F. Drug Addiction 2.08 1.12-3.88 SCRN Writing Group JAMA 2011 4
6/16/2017 Fetal Monitoring: How (What?) - Fetal Movement Of the following maternal risk factors, which has the • Decreased fetal movement � Fetal jeopardy highest adjusted odds ratio for stillbirth? – Women with stillbirth - >60% reported decreased FM OR 95% CI – Present w � FM ~25% abnormal finding/poor outcome 1. Smoking 1.55 1.02-2.35 – Balance: Appropriate alert vs. anxiety & unneeded intervention 2. Drug Addiction 2.08 1.12-3.88 – Routine (all) vs. “High risk” 3. AMA ≥ 40 2.41 1.24-4.70 Numerous techniques 4. Diabetes 2.50 1.39-4.48 • 10 movements in 12 hours of activity (Cardiff) 5. Multiple pregnancy 4.59 2.63-8.0 • 10 movements in 2 hours; 4 in 1h 6. Prior Stillbirth 5.91 3.18-11.0 • Count movements 1h 3/wk: = baseline • Subjective decreased fetal movement SCRN Writing Group JAMA 2011 Fetal Monitoring: How (What?) - Fetal Movement Fetal Monitoring: How (What)? Non-stress test • Cochrane – (RCTs) • FHR will accelerate with movement – No trials compared FM counting with No FM counting – No acidemia, not neurologically depressed – Routine fetal movement monitoring: • Reactivity • Identified more fetuses at ↑ risk of death – Indicates normal fetal autonomic function • No improvement in mortality – Non-reactive – sleep vs. other (mat meds) vs. acidemia • Non randomized studies • Semi-fowler - 20 min; Vibroacoustic stim x3 (VAS) – Reduction in perinatal death vs. standard care • Directed fetal movement counting vs. Optional • Reactive or Non-reactive • All methods may be similar – but women prefer Cardiff count to 10 – ≥2 accels (15pm x 15 sec) and moderate variability – No increase in maternal anxiety – GA: 24-28 weeks – 50% NR; 28-32wks 15% NR – Possibly increased attachment • <32 weeks use 10 x 10 accelerations Mangesi Cochrane 2015; Winje BA BJOG 2016 5
6/16/2017 Fetal Monitoring: How (What)? Non-stress test Fetal Monitoring: How (What)? CST • Contraction Stress Test: Fetal response to stress • Variables: non repetitive and brief <30 sec in duration • Advantage – Identify subtle hypoxia prior to acidosis – No additional follow-up • 3 UCs in 10 min • Variables: ≥3 in 20 min – At least 40 sec in duration – Associated with increased risk for CD NRFHT – IV/Oxytocin: 0.5mU/min – increase q20 (max 10mU/min) • Decelerations: >60 sec – Nipple stimulation – Associated with increased risk: • 50% Faster than IV oxytocin • CD for NRFHT – Contraindications (relative) • Stillbirth • PTL, PPROM, Previa, Vaginal Bleeding, Prior Classical CST Scoring: 2 components Fetal Monitoring: CST Management Component I CST result Follow-up Reactive – moderate variability, accels vs. Nonreactive Reactive-Negative Repeat in 7 days Component II Nonreactive-Negative Repeat -24h; unless <28wk • Negative: no significant decels – variable/late Reactive-Equivocal Repeat w/n 24h • Positive: ≥50% of UCs have late decelerations Nonreactive-Equivocal Repeat w/n 12-24h, Obs – ~50% adverse outcomes: CD for NRFHT, death, low Apgars – Positive CST not a contraindication to trial of labor Reactive-Positive Preterm: BPP, BMZ, cont FHR • Reactive, Positive CST Term: delivery, consider TOL • Equivocal: ≤50% decelerations with UCs Nonreactive-Positive Preterm: BPP, FHR, BMZ, prep – Tachysystole with q2 UCs/decels Term: delivery, CD – UC >90 seconds 6
6/16/2017 Fetal Monitoring: How (What)? Fetal Monitoring: How (What)? • Biophysical Profile –Scoring (0 or 2) • Biophysical Profile (BPP) – 5 components – Score has directly relationship to fetal pH – NST, may be omitted (4 components) • 8/8 or 8/10 or 10/10 - normal (unless oligohydramnios) – Breathing: ≥1 episode for 30 seconds within 30 min – Fetal pH – 7-35-7.40 – Movement: ≥3 discrete body/limb movements w/n 30min – Tone: ≥1 extension of a fetal extremity with return to flexion, or open/close of a hand – Amniotic fluid: 2cm pocket; AFI (chronic) Fetal Monitoring: How (What)? BPP – Score is 6/8 for oligohydramnios Which of the following is TRUE regarding oligohydramnios? • Biophysical Profile –Scoring (0 or 2) – Score has directly relationship to fetal pH A. Appropriate work/up includes a sterile speculum exam • 6/10 – Equivocal B. Deepest vertical pocket results in fewer unnecessary – Fetal pH - 7.32 69% interventions compared with %tile or AFI C. Delivery at 36-37 weeks is recommend • 2/10 or 4/10 abnormal D. At <36 weeks, US for EFW, continued surveillance via – pH 7.28 (4) 16% NST/BPP may be considered – pH 7.18 (2) 7% 7% 2% E. All of the above – pH 7.08 (0) 7
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