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 Objectives: Fetal monitoring - Who, When, How (What)? FM: Rationale • 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 • When? • ↓ Fetal renal perfusion ↓ Amniotic fluid – Gestational age, Risk factors, clinical scenario Modifiers, Disruptors and Confounders • How (What)? – Maternal medications, Fetal abnormalities (genetic, 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 FM: Rationale Of the following interventions, which is • Promote vaginal delivery/prevent CD? proven to prevent stillbirth? –Placenta “shelf life” 96% –Passenger grows A. Low dose Aspirin –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 2. Low molecular weight heparin – APA? • Birth plan • 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? • May lead to recommendation for Delivery (IOL) • Traditionally – those at increased risk for stillbirth – IOL - Side effects/Risks • Stillbirth causes/contributing factors: numerous • Oxytocin: Tachysystole, Hyponatremia – Risk factor (e.g., AMA or prior cesarean) ≠ Cause – Oxytocin not likely to be associated with Autism, Cesarean • Prostaglandins - Fever, nausea & vomiting • Demo : Black, ↓ Education, ↓SES, ↑ Maternal age • Uterine rupture (e.g., TOLAC) • Medical : Diabetes, Hypertension, Renal, Lupus, Cardiac • 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? 56% OR 95% CI 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 12% D. Smoking 1.55 1.02-2.35 E. AMA ≥ 40 10% 11% 5% 6% E. AMA ≥ 40 2.41 1.24-4.70 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 highest adjusted odds ratio for stillbirth? • Decreased fetal movement Fetal jeopardy – 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 SCRN Writing Group JAMA 2011 • Subjective decreased fetal movement 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: • Identified more fetuses at ↑ risk of death • Reactivity • No improvement in mortality – Indicates normal fetal autonomic function • Non randomized studies – Non-reactive – sleep vs. other (mat meds) vs. acidemia – Reduction in perinatal death vs. standard care • Semi-fowler - 20 min; Vibroacoustic stim x3 (VAS) • 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 – ~50% adverse outcomes: CD for NRFHT, death, low Apgars Nonreactive-Equivocal Repeat w/n 12-24h, Obs – 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 • Biophysical Profile –Scoring (0 or 2) Which of the following is TRUE regarding oligohydramnios? – Score has directly relationship to fetal pH • 6/10 – Equivocal A. Appropriate work/up includes a sterile speculum exam B. Deepest vertical pocket results in fewer unnecessary – Fetal pH - 7.32 69% interventions compared with %tile or AFI • 2/10 or 4/10 abnormal C. Delivery at 36-37 weeks is recommend – pH 7.28 (4) D. At <36 weeks, US for EFW, continued surveillance via 16% NST/BPP may be considered 7% 7% – pH 7.18 (2) 2% – pH 7.08 (0) E. All of the above 7 6/16/2017 BPP – Score is 6/8 for oligohydramnios Fetal Monitoring: Biophysical Profile (BPP) Which of the following is TRUE regarding oligohydramnios • If Oligohydramnios – work-up/evaluation vs. delivery 1. Appropriate work/up includes a sterile speculum exam 2. Deepest vertical pocket results in fewer unnecessary – History & PE including SSE interventions compared with %tile or AFI – DVP (2cm pocket without cord) • Fewer unnecessary interventions 3. Delivery at 36-37 weeks is recommend • No increased risk of poor outcomes 4. At <36 weeks, US for EFW, continued surveillance via – Delivery (ACOG): 36-37 weeks NST/BPP may be considered – <36 weeks, Individualize assessment & treatment 5. All of the above • US for EFW – If IUGR Doppler • Frequent/Continuous fetal surveillance NST/BPP • If <37 weeks consider BMZ Fetal Monitoring: How (What)? Fetal Monitoring: Performance • Modified Biophysical Profile • False negative – NST (acute) Stillbirth