ANTEPARTUM NONSTRESS TESTING FREQUENCY ULTRASOUND SURVEILLANCE PROCEDURE Guidelines for Minimum Frequency of Antepartum Nonstress Testing and Ultrasound Surveillance For all Outpatient Bookings, the following is required: 1.Greater than or equal to 26 weeks gestation 3.Antenatal Records Parts 1 and 2 2.Plan to deliver at BC Women’s 4. Ultrasound report Applicability: Antenatal fetal surveillance occurs in the Antepartum and Maternal Ambulatory Programs. Type of Minimum Indication Definition/details When to start Surveillance Frequency One or more of the following: Per EMMA . Low PAPP-A (less Growth ultrasound guidelines (or than 0.15 MoM) equivalent) Abnormal serum . High AFP (greater screen than 2.50 MoM) . High hCG (greater than 4.00 MoM) Per IUGR or GHTN/ NST, AFI & UA Doppler only if IUGR, . High Inhibin A (greater pre-eclampsia GHTN or pre-eclampsia than 3.00 MoM) guidelines . E3 (estriol) (less than 0.4 MoM) Advanced maternal 40 years age or more at NST & AFV 2x/ week 39 weeks age EDD assessment Antepartum As clinically Inpatient NST At diagnosis* hemorrhage indicated Abruption (Chronic) Outpatient NST Weekly At diagnosis* Assisted reproductive As per other indications as they arise technology pregnancy Weekly (or At diagnosis (if increase as NST greater than or Cholestasis of Pruritis without rash with clinically equal to 28 weeks) pregnancy or without abnormal liver indicated) enzymes As clinically Ultrasound indicated NST Ultrasound within 24 Decreased fetal Once (or more if Less than 6 distinct fetal hours (if high risk movement indicated by At diagnosis* movements in 2 hours factors or suspicion findings) of IUGR or oligo- hydramnios) WW.04.04A Fetal Maternal Newborn and Family Health Policy & Procedure Manual Effective Date: 03-May-2018 Review Date: 03-May-2021 Refer to online version – Print copy may not be current – Discard after use Page 1 of 5 ANTEPARTUM NONSTRESS TESTING FREQUENCY ULTRASOUND SURVEILLANCE Type of Indication Definition/details Frequency When to start Surveillance type 1 or type 2 (HbA1c Growth ultrasound Screening 30 - 32 weeks Diabetes, insulin- less than 7% and normal NST Weekly 36 weeks requiring fetal growth) Well-controlled Growth ultrasound Screening 30 - 32 weeks Gestational NST Weekly 36 weeks -type 1 and 2: (HbA1c > Based on 28 -32 weeks Growth ultrasound 7% and asymmetric clinical findings Repeat PRN Diabetes, insulin- macrosomia) requiring continued -gestational: suboptimal NST 2x/ week 32 weeks glucose control &/or Poorly controlled asymmetric macrosomia) When clinically Growth ultrasound Falling insulin indicated requirements NST 2x/ week NST, AFI & UA Gastroschisis Weekly 34 weeks Doppler BP greater than or equal to 140 and/or dBP NST, AFI & UAD 2x/ week Hypertension greater than or equal to -gestational and pre- 90 At diagnosis* eclampsia Severity requiring NST Daily admission AFI & UA Doppler 2x/ week BP ≥ 140 and/or dBP ≥ Hypertension 90 before 20 weeks or NST, AFI & UAD once/ week 35 weeks -pre-existing/chronic anti-hypertensive therapy before 20 weeks Isolated severe NST 2x/ week At diagnosis* oligohydramnios (with DVP less than 2 cm AFI & UA Doppler 2x/ week At diagnosis* intact membranes) Mild (AC 5th- 9th centile) Weekly IUGR* with Normal Moderate (AC 1st - 4th Fluid and Doppler - NST, AFI & UA 2x/ week consult OB/MFM if centile) At diagnosis* Doppler AEDF/ REDF in Severe (AC less than 1st 3x/ week ongoing pregnancies centile) Isolated NST and AFI AFI > 250mm Weekly At diagnosis* Polyhydramnios Doppler Maternal conditions (SLE, renal disease, As indicated by co-morbid conditions (hypertension, IUGR, etc.) APAS, etc.) Pre-pregnancy BMI Morbid Obesity greater than or equal to NST Weekly 34 weeks 35 kg/m2 WW.04.04A Fetal Maternal Newborn and Family Health Policy & Procedure Manual Effective Date: 03-May-2018 Review Date: 03-May-2021 Refer to online version – Print copy may not be current – Discard after use Page 2 of 5 ANTEPARTUM NONSTRESS TESTING FREQUENCY ULTRASOUND SURVEILLANCE Type of Indication Definition/details Frequency When to start Surveillance Contractions less than 1 Continuous EFM x 4 in 10 min, no vaginal hours from bleeding, no abdominal Motor Vehicle admission pain and normal FHR Accident At diagnosis* Regular contractions, Continuous EFM x vaginal bleeding, ABN 24 hours from the FHR, pain, low platelets event or fibrinogen Ultrasound Every 3-4 weeks 18-20 weeks Dichorionic twins and 37 weeks for twins trichorionic triplets NST 2x/ week 35 weeks for triplets Ultrasound Every 2 weeks 16 weeks Monochorionic diamniotic 36 weeks for twins twins NST 2x/ week Multiple gestations 34 weeks for triplets (assuming no other Growth ultrasound Every 2 weeks 16 weeks complications or Monoamniotic twins IUGR) AFI & UA Doppler 2x/ week At admission (based on GA for NST 2x/ day intervention) TTTS Ultrasound At least weekly At diagnosis No laser NST At least 2x/ week At diagnosis* Weekly x 4, then Laser or Ultrasound From procedure time every 2 weeks Bipolar or Selective Reduction NST 2x/ week 34 wks Maternal age less than NST & AFV Post dates 2x/ week 41 weeks 40 years assessment PPROM NST 3x/ week At diagnosis* While on maintenance NST Daily tocolysis for 48 hours Preterm labour At diagnosis* Once contractions have Only if preterm NST stopped completely labour returns Serum screening for placental evaluation Previous IUFD of 32 weeks or 1-2 unknown etiology in NST, AFI & UA Previous stillbirth Weekly weeks before second or third trimester Doppler previous IUFD Growth ultrasound Every 4 weeks 28 weeks At significant titre or Kell antibody: at any titre Growth ultrasound 20 weeks previous and MCA Doppler as As per MCA Red blood cell allo- Other significant affected pregnancy/ per Mari chart and PSV chart immunization antibodies: once titre Kell allo- trend greater than or equal to immunization 1:16 NST Weekly 32 weeks WW.04.04A Fetal Maternal Newborn and Family Health Policy & Procedure Manual Effective Date: 03-May-2018 Review Date: 03-May-2021 Refer to online version – Print copy may not be current – Discard after use Page 3 of 5 ANTEPARTUM NONSTRESS TESTING FREQUENCY ULTRASOUND SURVEILLANCE Type of Indication Definition/details Frequency When to start Surveillance -Perform NST prior to As per obstetrical NST methadone dose or indication minimum 8 hours post Once at methadone dose NST Substance use readmission -Perform on admission or After 28 weeks Ultrasound within 24 readmission after hours (if high risk As per OB absence against medical factors or suspicion indication advice or for other of IUGR or oligo- obstetrical indication. hydramnios) * Provided fetus(es) at a gestational age and estimated weight compatible with option for intervention. Key: AC = Abdominal Circumference etc = et cetera MoM = multiples of the median AFI = amniotic fluid index; FHR = fetal heart rate NST = nonstress test AFV = amniotic fluid volume GA = gestational age PAPP-A = pregnancy associated plasma protein A APAS = antiphospholipid antibody syndroome GHTN = gestational hypertension PRN = as needed BMI = basal metabolic index hCG = human chorionic gonadotropin sBP = systolic blood pressure dBP = diastolic blood pressure IUFD = intrauterine fetal demise SLE = systemic lupus erythematosus DVP = Deepest vertical pocket IUGR = intrauterine growth restriction TTTS = twin to twin transfusion syndrome EDD = expected date of delivery kg/m2 = kilograms per metre squared UA = umbilical artery EFM = electronic fetal monitoring MCA doppler = middle cerebral artery x = times EMMA = evaluating maternal markers of acquired risk for pre-eclampsia REFERENCES 1. Bahtiyar MO, Funai EF, Rosenberg V, Norwitz E, Lipkind H, Buhimschi C, et al. 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SOGC Clinical Practice Guideline, No. 307, May 2014. Journal of obstetrics and gynaecology Canada J Obstet Gynaecol Can 2014;36(5):416–438 10. NICE. Hypertension in pregnancy: diagnosis and management. Clinical guideline [CG107] Published date: updated: January 2011 National Institute for Health and Clinical Excellence. WW.04.04A Fetal Maternal Newborn and Family Health Policy & Procedure Manual Effective Date: 03-May-2018 Review Date: 03-May-2021 Refer to online version – Print copy may not be current – Discard after use Page 4 of 5 ANTEPARTUM NONSTRESS TESTING FREQUENCY ULTRASOUND SURVEILLANCE 11. Cedergren MI. Maternal morbid obesity and the risk of adverse pregnancy outcome.