approach to evidence based antenatal Fetal survelliance
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This document discusses evidence-based approaches to antenatal Doppler fetal surveillance. It begins by outlining the objectives and aims of fetal surveillance, including identifying fetuses at risk of hypoxia and improving perinatal outcomes. It then describes various methods of fetal surveillance, including daily fetal movement counts, non-stress tests, biophysical profiles, and Doppler velocimetry. The document discusses the indications and measurements of Doppler indices for the uterine, umbilical, and middle cerebral arteries. It reviews recent evidence showing that Doppler ultrasound in high-risk pregnancies can reduce perinatal deaths and interventions without increasing them in low-risk pregnancies. The document concludes by emphasizing that not all pregnancies require surveillance and that monitoring
![TRUFFLE trial
• (O) Primary outcome: Survival without cerebral palsy or neurosensory impairment, or a
Bayley III developmental score of less than 85, at 2 years of age
• Result :The proportion of infants surviving without neuro-impairment did not differ
between the CTG STV (111 [77%] of 144 infants with known outcome), DV p95 (119 [84%] of
142), and DV no A (133 [85%] of 157) groups (ptrend=0·09)
Concluded : The proportion of infants who survived without neurodevelopmental impairment between the
three groups did not differ; neurodevelopmental impairment was least frequent in survivors randomly
assigned to the DV no A group compared with those in the CTG STV group (p trend across the three groups of
0·004). Their findings support waiting for late ductus venosus changes before delivery because no increase in
hypoxia mediated deaths occurred and neuro-impairment is less frequent than when delivery is based on
computerised CTG changes.](https://image.slidesharecdn.com/fetalsurvelliance-220102180958/85/approach-to-evidence-based-antenatal-Fetal-survelliance-33-320.jpg)
approach to evidence based antenatal Fetal survelliance
- 1. Evidence Based Approach To Antenatal Doppler Fetal Surveillance DR PRAMAN KUSHWAH DrNB NEONATOLOGY RESIDENT NICE HOSPITAL, HYDERABAD
- 2. Objectives 1. Aim of fetal surveliiance 2. Methods of fetal survelliance 3. Indication for fetal survelliance 4. Fetal Doppler in fetal survelliance – Indices and Measurements 5. Uterine, Umbilical and Middle cerebral artery Doppler 6. Recent Evidences
- 3. Aim Of Fetal Surveillance • Identifying fetus at greater risk of hypoxia • Minimizing the morbidity by optimizing the timing of delivery • Improving perinatal outcomes by decreasing stillbirths and perinatal asphyxia • Improve long term neurologic outcomes by timely intervention • Relies on fetal biophysical parameters (eg. heart rate and movement) that are sensitive to hypoxemia and acidemia • FIGO recommends to begin at 24-28 weeks in high risk patients.
- 4. Daily Fetal Movement Count Non Stress Test Contraction stress test Manning score or biophysical profile Doppler Velocimetry Methods Of Fetal Surveillance Cardiff Method : Count of 10 fetal movements in 12 hours Designed to evaluate FHR response to maternal uterine contractions Describes fetal heart rate acceleration to fetal movement as a sign of fetal health
- 5. Biophysical Profile Non Stress Test • At least one episode continuing for more than 30 seconds Fetal Breathing movements • At least 3 limb or body movements Gross Body Movements • An episode of active extension with return to flexion of a limb or trunk OR opening or closing of the hand Fetal Muscle Tone • At least one cord and limb-free fluid pocket which is 2 cm by 2 cm in two measurements at right angles. Amniotic fluid volume Manning et al, 1980
- 6. Fanaroff and Martin’s Neonatal-Perinatal Medicine, Diseases of the fetus and infant, 10th edition
- 7. Fetal Doppler In Antenatal Surveillance •For evaluation of high-risk pregnancies especially, FGR is suspected with EFW < 10th centile. •Doppler sonography has both diagnostic and predictive value in fetus with potential FGR. •Doppler USG of fetal vessels can identify the SGA from true FGR fetus, thus avoiding iatrogenic prematurity and additional antenatal testing.
- 8. Objective : To assess the effects on obstetric practice and pregnancy outcome of routine fetal and umbilical Doppler ultrasound in unselected and low-risk pregnancies. Population : Included five trials that recruited 14,624 women, with data analysed for 14,185 women. Result : No group differences noted for the review’s primary outcomes of perinatal death and neonatal morbidity. Routine fetal and umbilical Doppler ultrasound examination in low-risk or unselected populations did not result in increased antenatal, obstetric and neonatal interventions. Cochrane Database of Systematic Reviews 2015, Issue 4. Art. No.: CD001450.
- 9. • Objective: To assess the effects of Doppler ultrasound used in high-risk pregnancies on obstetric care and fetal outcomes • Selection criteria: Nineteen trials involving 10,667 women were included (high risk pregnancies) were included, compared the use of Doppler ultrasound of the umbilical artery of the unborn baby with no Doppler or with cardiotocography (CTG). • Results: The use of Doppler ultrasound in high-risk pregnancy was associated with a reduction in perinatal deaths (29%) with fewer inductions of labour and fewer caesarean sections. No difference was found in operative vaginal births nor in Apgar scores less than seven at five minutes Cochrane Database of Systematic Reviews 2017, Issue 6. Art. No.: CD007529.
- 10. Pathophysiological Basis Of Antenatal Doppler Doppler Velocimetry for Fetal Surveillance: Adverse Perinatal Outcome and Fetal Hypoxia. Dev Maulik, Reinaldo Figueroa. 2006 Fetus responds to chronic hypoxemia with a detectable sequence of biophysical changes Physiological adaptation → physiological decompensation DU may not identify fetuses at risk of death from an acute hypoxemic insult, such as a complete placental abruption.
- 11. Stress Chronic respiratory and nutritive insufficiency Primary adaptive response Decreased fetal growth rate Secondary adaptive response Fetal energy conservation – decr. HR reactivity, fetal movement Circulatory redistribution – doppler changes Fetal growth preferred over placental growth Increased efficiency of placental exchange Polycythemia Fetal Response To Chronic Intrauterine Hypoxia
- 12. Stress Chronic respiratory and nutritive insufficiency Primary adaptive response Decreased fetal growth rate Secondary adaptive response Fetal energy conservation – dec HR reactivity, fetal movement Circulatory redistribution – doppler changes Fetal growth preferred over placental growth Increased efficiency of placental exchange Polycythemia Progressive decompensation Hypoxia respiratory acidosis metabolic acidosis High impedance in fetoplacental and systemic circulation– AEDF in UA Declining AFI Oligohydramnios Loss of fetal movement, HR variability Persistent late de-accelerations Death Doppler Velocimetry for Fetal Surveillance: Adverse Perinatal Outcome and Fetal Hypoxia. Dev Maulik, Reinaldo Figueroa. 2006
- 13. Doppler USG - History • DU was successfully introduced in OBG in 1977. • Fitzgerald et al. were the first to report noninvasive demonstration of the umbilical cord (UC) blood flow pattern and suggested that the umbilical artery (UA) waveforms could be abnormal in fetuses with intrauterine growth-restriction (IUGR).
- 14. Doppler Velocimetry - Uses • Non-invasive measurement of blood flow in maternal and fetal blood vessels • Assesses uteroplacental blood flow and fetal physiological responses. • DU waveforms- not only reflect blood velocity but also presence and direction of flow, velocity profile, flow volume, and impedance.
- 15. Doppler Indices • Angle-independent, doppler indices mentioned below were developed for flow velocimetry to avoid inter- and intra-observer variation
- 16. Doppler Indices Doppler Imaging Ultrasonography in Assessment of Fetal Well-being NeoReviews Vol.5 No.6 June 2004
- 17. Doppler Assessment • UTERINE ARTERY • UMBILICAL ARTERY • MIDDLE CEREBRAL ARTERY • VENOUS (UV,DV,IVC)
- 18. Uterine Artery Doppler • Uterine artery re-modelling is the hallmark of successful placentation. • In normal pregnancy, placental trophoblast cells invade the inner third of the myometrium optimizing delivery of oxygen and nutrients to the fetus. • Significant increase in uterine artery compliance increased flow in diastole. • In preeclampsia failure of trophoblast invasion of the uterine muscular wall spiral arteries retain the muscle elastic coating impedance to blood flow persists. • PI > 95th or persistent diastolic notch done in 2nd trimester predict pre-eclampsia and IUGR Uterine artery Doppler flow studies in obstetric practice Journal of Prenatal Medicine 2010; 4 (4): 59-62
- 19. Normal uterine artery at 12 weeks shows relatively high resistance, absent notching Normal mid-trimester uterine artery, increased diastolic flow Normal third trimester uterine artery, very low resistance High resistance with persistent notching may be normal in first trimester, not in this 24-week gestation USG Very high resistance, marked notching, absent diastolic velocities in a woman with lupus, proteinuric pre-eclampsia, and severe IUGR at 28 weeks
- 20. Umbilical Artery Doppler • Umbilical artery (UA)- most easily measured parameter • Measure of fetal systemic and placental vascular impedance. • Placentas with abnormal UA doppler have slender capillaries with decreased capillary loops in gas-exchanging terminal villi. • Maternal or placental conditions that obliterate small muscular arteries in the placental tertiary stem villi result in a progressive decrease in end-diastolic flow in the umbilical artery Doppler waveform until absent. • REDF has been shown to be associated with obliteration of >70% of placental tertiary villi. Doppler Imaging Ultrasonography in Assessment of Fetal Well-being NeoReviews Vol.5 No.6 June 2004 Antenatal tests of fetal wellbeing. Seminars in Fetal & Neonatal Medicine 20 (2015) 138e143
- 21. Umbilical Artery Doppler Normal umbilical artery at 18 weeks shows relatively high resistance, but consistent diastolic flow Normal umbilical artery at 36 weeks, low resistance, generous diastolic flow High resistance, diastolic velocity low Absent end-diastolic velocity (AEDV) Reversed diastolic velocity (REDV) in severe intrauterine growth restriction (IUGR)
- 22. Abnormal UA Doppler 1. Prediction of fetal hypoxia and acidosis especially if AEDF 2. A/REDF higher adverse perinatal outcomes, increased perinatal mortality upto 28% and increased requirement of intensive care. 3. Higher prevalence of doppler abnormalities seen in chromosomal disorders (especially trisomy 13, 18, and 21) and congenital anomalies. 4. Many studies have shown that abnormal doppler findings esp A/REDF are associated with long term neurodevelopmental impairment. Baschat AA, Viscardi RM, Hussey-Gardner B, et al. Infant neurodevelopment following fetal growth restriction: relationship with antepartum surveillance parameters. Ultrasound Obstet Gynecol 2009;33:44–50.
- 23. MCA Doppler 1) To detect evidence of redistribution of fetal blood flow to the brain in cases of placental insufficiency, fetal hypoxia, and associated fetal growth restriction 2) To detect increased blood flow to the brain in cases of fetal anemia.
- 24. MCA Doppler And IUGR • MCA resistance is normally high throughout gestation. • Increased MCA diastolic velocity in FGR i.e. ‘brain-sparing’ effect secondary to hypoxia- induced cerebrovascular dilation • Represents a deterioration in placental respiratory function decrease in PI. • These compensatory changes are sequential • Depend on the maintenance of adequate cardiac output. • When IUGR becomes terminal, falling cardiac function may result in the regression of MCA flow, so- called ‘pseudo - normalization’
- 25. Normal middle cerebral artery (MCA) at term – normal peak systolic velocity (58 cm/s), high resistance, low end-diastolic velocity. ‘Brain sparing’ MCA – lower peak, much higher diastolic velocity suggests cerebro-vasodilation Anemic fetus with retained high resistance, elevated peak systolic velocity (77 cm/s).
- 26. Cerebroplacental Ratio • The CPR is calculated as the ratio of doppler index (pulsatility index (PI), resistance index (RI), or systolic/diastolic ratio (S/D)) of the MCA by that of the UA. Most commonly PI is used. • High UA PI values and low MCA PI values are associated with adverse outcomes. • Low CPR (<1) risk of adverse perinatal outcome. Cerebro-placental Ratio = Middle Cerebral Artery PI Umbilical Artery PI Predictive accuracy of cerebroplacental ratio for adverse perinatal and neurodevelopmental outcomes in suspected fetal growth restriction: systematic review and meta-analysis. Ultrasound Obstet Gynecol 2018; 52: 430–441.
- 27. MCA Doppler And Fetal Anemia • MCA PSV (Peak Systolic Velocity) risk of Rh disease or anemia due to parvovirus B19. • Raised PSV but antibody is negative acute or chronic feto-maternal haemorrhage • For Rh sensitization – done as early as 16-18 weeks, repeated 1-2 weeks interval • The sensitivity of increased MCA PSV for the prediction of mod-severe anemia was 100% either in the presence or absence of hydrops, with a false positive rate of 12%.
- 28. Fetal Anemia Fetal anemia progresses (decreased viscosity) Right and left ventricular output increases by 45%, heart rate unchanged Fetal blood vessel cross sectional area unchanged Poiseuille’s law (velocity directly proportional to flow) (flow=velocity X cross sectional area) Increased flow Normal Fetal anemia
- 30. GRIT (Growth Restriction Intervention Trial) • Population: 69 hospitals in 13 European countries, 1997-2003. 587 babies, 24-36 weeks gestation with IUGR and abnormal doppler. • Aim: Aim was to compare the effect of delivering early to avoid intrauterine hypoxia, to delaying delivery for as long as possible, in order to gain maturity • Result: Median time-to-delivery interval - 0.9 days in immediate group and 4.9 days in delay group. Total deaths prior to discharge were 29 (10%) in the immediate group versus 27 (9%) in the delay group.
- 31. Lancet 2004; 364: 513–2 Conclusion : At 2 years of age, there is a trend towards more disability in the immediate delivery group, but no overall difference in Griffiths DQ.
- 32. TRUFFLE trial • (P) Trial of Umbilical and Fetal Flow in Europe 20 European perinatal centers, 2005 – 2010. Women with a singleton fetus, 26–32 weeks, AC < 10th percentile and UA PI >95th percentile • (I) AIM: To assess whether changes in the fetal ductus venosus Doppler waveform (DV) could be used as indications for delivery instead of cardiotocography short-term variation (STV) • 3 armed RCT: Group 1: control - current standard of care: timing of delivery based on CTG low STV(red HR) Group 2a: Early ductus venosus changes (PI > 95th centile) Group 2b: Late ductus venosus changes (absent a-wave) Lancet 2015; 385: 2162–72
- 33. TRUFFLE trial • (O) Primary outcome: Survival without cerebral palsy or neurosensory impairment, or a Bayley III developmental score of less than 85, at 2 years of age • Result :The proportion of infants surviving without neuro-impairment did not differ between the CTG STV (111 [77%] of 144 infants with known outcome), DV p95 (119 [84%] of 142), and DV no A (133 [85%] of 157) groups (ptrend=0·09) Concluded : The proportion of infants who survived without neurodevelopmental impairment between the three groups did not differ; neurodevelopmental impairment was least frequent in survivors randomly assigned to the DV no A group compared with those in the CTG STV group (p trend across the three groups of 0·004). Their findings support waiting for late ductus venosus changes before delivery because no increase in hypoxia mediated deaths occurred and neuro-impairment is less frequent than when delivery is based on computerised CTG changes.
- 35. Take home message • All Pregnancies do not require Antepartum fetal surveillance with doppler • High risk pregnancies should be identified timely and appropriate fetal monitoring should be initiated • Early and late onset FGR have different pathophysiology and different findings on fetal surveillance • Umbilical Artery dopplers have limited role in late onset FGR. • Monitoring should be based on integration of Doppler, BPP, NST rather than one test alone. • Timing of delivery should be individualized for each patient.
- 36. Thank You