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Obstentrics_Williams. McCullough LB, Chervenak FA, Brent L, et al: A case study in unethical transgressive bioethics: "Letter of Concern from Bioethicists" about the prenatal administration of dexamethasone. Am J Bioeth 10(9):35,2010 McElhinney DB, Marshall A, Wilkins-Haug LE, et l: Predictors of technical success and postnatal biventricular outcome after in utero aortic valvuloplasty for aortic stenosis with evolving hypoplastic left heart syndrome. Circulation 120(15):1482,o2009 McElhinney DB, Tworetsky W, Lock JE: Current status of fetal cardiac intervention. Circulation 121(10):1256,o2010 Metkus AP, Filly RA, Stringer MD, et al: Sonographic predictors of survival in fetal diaphragmatic hernia. J Pediatr Surg 31 (1): 148, 1996 Meuli M, Meuli-Simmen C, Hutchins GM, et al: In utero surgery rescues neurological function at birth in sheep with spina biida. Nat Med 1 (4) :342, 1995


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Obstentrics_Williams. Meuli M, Meuli-Simmen C, Hutchins GM, et al: In utero surgery rescues neurological function at birth in sheep with spina biida. Nat Med 1 (4) :342, 1995 Meuli M, Meuli-Simmen C, Hutchins GM, et al: he spinal cord lesion in human fetuses with myelomeningocele: implications for fetal surgery. J Pediatr Surg 32(3):448, 1997 Miller L, Witchel SF: Prenatal treatment of congenital adrenal hyperplasia: risks outweigh beneits. Am J Obstet GynecoIo208(5):354, 2013 Moldenhauer JS: Ex utero intrapartum therapy. Semin Pediatr Surg 22(1):44, 20o13 Moon-Grady AJ, Morris SA, Belfort M, et al: International Fetal Cardiac Intervention Registry. A worldwide collaborative description and preliminary outcomes.o] Am Coli CardioIo66(4):388, 2015 Morris LM, Lim FY, Crombleholme TM: Ex utero intrapartum treatment procedure: a peripartum management strategy in particularly challenging cases. J Pediatr 154(1):126, 2009a


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Obstentrics_Williams. Morris LM, Lim FY, Crombleholme TM: Ex utero intrapartum treatment procedure: a peripartum management strategy in particularly challenging cases. J Pediatr 154(1):126, 2009a Morris LM, Lim FY, Elluru RG, et al: Severe micrognathia: indications for EXIT-to-Aiway. Fetal Diagn Ther 26: 162, 2009b Morris RK, Malin GL, Quinlan-Jones E, et al: Percutaneous vesicoamniotic shunting versus conservative management in fetal lower urinary tract obstruction (PLUTO): a randomized trial. Lancet 382(9903):1496,o2013 Mullassety 0, Ba'ath ME, Jesudason EC, et al: Value of liver herniation in prediction of outcome in fetal congenital diaphragmatic hernia: a systematic review and meta-analysis. Ultrasound Obstet Gynecol 35(5):609, 2010 New MI, Abraham M, Yuen T, et al: An update on prenatal diagnosis and treatment of congenital adrenal hyperplasia. Semin Reprod Med 30(5):396,


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Obstentrics_Williams. New MI, Tong K, Yuen T, et al: Noninvasive prenatal diagnosis of congenital adrenal hyperplasia using cell-free DNA in maternal plasma. J Clin Endocrinol Metab 99(6):E1022, 2014 Nimkan S, Gangishetti PK, Yau M, et al: 21-Hydroxylase deicient congenital adrenal hyperplasia. In Pagon RA, Adam MP, Ardinger HH, et al (eds): GeneReviews. Seattle, University of Washington, 2016 Noah �IM, Norton ME, Sandberg P, et al: Short-term maternal outcomes that are associated with the EXIT procedure, as compared with cesarean delivery. Am J Obstet Gynecol 186(4):773,o2002 Overcash RT, Marc-Aurele KL, Hull AD, et l: Maternal iodine exposure: a case offetal goiter and neonatal hearing loss. Pediatrics 137(4):el, 2016 Oluyomi-Obi T, Kuret V, Puligandla P, et l: Antenatal predictors of outcome in prenatally diagnosed congenital diaphragmatic hernia (CDH). J Pediatr Surg 52(5):881, 2017


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Obstentrics_Williams. Oluyomi-Obi T, Kuret V, Puligandla P, et l: Antenatal predictors of outcome in prenatally diagnosed congenital diaphragmatic hernia (CDH). J Pediatr Surg 52(5):881, 2017 Peleg 0, Cada S, Peleg A, et al: he relationship between maternal serum thyroid-stimulating immunoglobulin and neonatal thyrotoxicosis. Obstet GynecoIo99(6):1040,o2002 Peralta CF, Cavoretto P, Csapo B, et al: Assessment of lung area in normal fetuses at 12-32 weeks. Ultrasound Obstet Gynecol 26(7):718, 2005 Peranteau H, Boelig MM, Khalek N, et al: Efect of single and multiple courses of maternal betamethasone on prenatal congenital lung lesion growth and fetal survival. J Pediatr Surg 51(1):28,o2016 Quintero RA, Morales J, Allen MH, et al: Staging of twin-twin transfusion syndrome. J Perinatol 19:550, 1999 Ribault V, Castanet M, Bertrand vI,et al: Experience with intraamniotic thyroxine treatment in nonimmune fetal goitrous hypothyroidism in 12 cases. J Clin Endocrinol Metab 94:3731, 2009


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Obstentrics_Williams. Ribault V, Castanet M, Bertrand vI,et al: Experience with intraamniotic thyroxine treatment in nonimmune fetal goitrous hypothyroidism in 12 cases. J Clin Endocrinol Metab 94:3731, 2009 Robyr R, Lewi L, Salomon LJ, et al: Prevalence and management of late fetal complications following successful selective laser coagulation of chorionic plate anastomoses in twin-to-twin transfusion syndrome. Am J Obstet Gynecol 194(3):796,o2006 Ruano R, Lazar DA, Cass DL, et al: Fetal lung volume and quantification of liver herniation by magnetic resonance imaging in isolated congenital diaphragmatic hernia. Ultrasound Obstet GynecoIo43(6):662, 2014 Ruano R, Rodo C, Peiro JL, et al: Fetoscopic laser ablation of placental anastomoses in twin-twin transfusion syndrome using "Solomon technique." Ultrasound Obstet GynecoIo42(4):434, 2013


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Obstentrics_Williams. Ruano R, Rodo C, Peiro JL, et al: Fetoscopic laser ablation of placental anastomoses in twin-twin transfusion syndrome using "Solomon technique." Ultrasound Obstet GynecoIo42(4):434, 2013 Ruano R, Yoshisaki CT, da Silva MM, et 1: A randomized controlled trial of fetal endoscopic tracheal occlusion versus postnatal management of severe isolated congenital diaphragmatic hernia. Ultrasound Obstet Gynecol 39(1):20, Shah A, Moon-Grady A, Bhogal N, et al: Efectiveness of sotalol as irstline therapy for fetal supraventricular tachyarrhythmias. Am J Cardiol 190(1o1):1614,o2012 Shamshirsaz A, Ramin, SM, Belfort A: Fetal therapy. In Yeomans ER, Hofman BL, Gilstrap LC III, et al: Cunningham and Gilstrap's Operative Obstetrics, 3rd ed. New York, McGraw-Hill Education, 2017


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Obstentrics_Williams. Shamshirsaz A, Ramin, SM, Belfort A: Fetal therapy. In Yeomans ER, Hofman BL, Gilstrap LC III, et al: Cunningham and Gilstrap's Operative Obstetrics, 3rd ed. New York, McGraw-Hill Education, 2017 Shieh HF, Wilson JM, Sheils CA, et a1: Does the ex utero intrapartum treatment to extracorporeal membrane oxygenation procedure change morbidity outcomes for high-risk congenital diaphragmatic hernia survivors? J Pediatr Surg 52(1):22,o2017 Shue E, Bolouri M, Jelin EB, et a1: Tumor metrics and morphology predict poor prognosis in prenatally diagnosed sacrococcygeal teratoma: a 25-year experience at a single institution. J Pediatr Surg 48(6):1225,o2013 Slaghekke F, Lewi L, Middeldorp JM, et al: Residual anastomoses in twintwin transfusion syndrome after laser: the Solomon randomized trial. Am J Obstet GynecoI211(3):285.el, 2014a


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Obstentrics_Williams. Slaghekke F, Lewi L, Middeldorp JM, et al: Residual anastomoses in twintwin transfusion syndrome after laser: the Solomon randomized trial. Am J Obstet GynecoI211(3):285.el, 2014a Slaghekke F, Lopriore E, Lewi L, et a1: Fetoscopic laser coagulation of the vascular equator versus selective coagulation for twin-to-twin transfusion syndrome: an open-label randomized controlled trial. Lancet 383(9935):2144, 2014b Society for Maternal-Fetal Medicine, Simpson LL: Twin-twin transfusion syndrome. Am J Obstet Gynecol 208(1):3, 2013 Speiser PW, Azziz, Baskin LS, et a1: Congenital adrenal hyperplasia due to steroid 21o-hydroxylase deficiency: an Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab 95(9):4133, 2010 Srinivasan S, Strasburger J: Overview of fetal arrhythmias. Curr Opin Pediatr 20:522, 2008 Srisupundit K, Sirichotiyakul S, Tongprasent F, et al: Fetal therapy in fetal thyrotoxicosis: a case report. Fetal Diagn her 23(2):1o14,o2008


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Obstentrics_Williams. Srisupundit K, Sirichotiyakul S, Tongprasent F, et al: Fetal therapy in fetal thyrotoxicosis: a case report. Fetal Diagn her 23(2):1o14,o2008 Stofan AP, Wilson J, Jennings RW, et al: Does the ex utero intrapartum treatment to extracorporeal membrane oxygenation procedure change outcomes for high-risk patients with congenital diaphragmatic hernia? J Pediatr Surg 47(6):1053,o2012 Strasburger JF, Wakai RT: Fetal cardiac arrhythmia detection and in utero therapy. Nat Rev (5):277,o2010 Sugibayashi R, Ozawa K, Sumie M, et a1: Forty cases of twin reversed arterial perfusion sequence treated with radio frequency ablation using the multistep coagulation method: a single-center experience. Prenat Diagn 36(5):437, 2016 Sutton LN, Adzick NS, Bilaniuk LT, et al: Improvement in hindbrain herniation demonstrated by serial fetal magnetic resonance imaging following fetal srgery for myelomeningocele. JAMA 282(19):1826, 1999


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Obstentrics_Williams. Swamy R, Embleton N, Hale J, et al: Sacrococcygeal teratoma over two decades: birth prevalence, prenatal diagnosis and clinical outcomes. Prenat Diagn 28: 1048, 2008 Van der Heijden LB, Oudijk MA, Manten GTR, et a1: Sotalol as irst-line treatment for fetal tachycardia and neonatal follow-up. Ultrasound Obstet GynecoIo42(3):285,o2013 Ville Y, Hyett J, Hecher K, et a1: Preliminary experience with endoscopic laser surgery for severe twin-twin transfusion syndrome. N Engl J Med 332(4):224, 1995 Vrecenak JD, Flake A W: Fetal surgical intervention: progress and perspectives. Pediatr Surg Int 29(5):407,o2013


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Obstentrics_Williams. Vrecenak JD, Flake A W: Fetal surgical intervention: progress and perspectives. Pediatr Surg Int 29(5):407,o2013 Walsh WF, Chescheir NC, Gillam-Krakauer M, et al: Maternal-fetal surgical procedures. Technical Brief No. 5. AHRQ Publication No.o1 0(1)-EHC059EF, Rockville, Agency for Healthcare Research and Quality, 201o1 Wilson RD, Lemerand K, Johnson MP, et a1: Reproductive outcomes in subsequent pregnancies after a pregnancy complicated by open maternal-fetal srgery (1996-2007). Am J Obstet Gynecol 203(3):209.el, 2010 Worley KC, Dashe JS, Barber RG, et al: Fetal magnetic resonance imaging in isolated diaphragmatic hernia: volume of herniated liver and neonatal outcome. Am J Obstet Gynecol 200:318.el, 2009 Wu D, Ball RH: The maternal side of maternal-fetal surgery. Clin Perinatol 36(2):247, 2009 Yinon Y, Grisaru-Granovsky S, Chaddha V, et al: Perinatal outcome following fetal chest shunt insertion for pleural efusion. Ultrasound Obstet Gynecol 36:58,o2010


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Obstentrics_Williams. Yinon Y, Grisaru-Granovsky S, Chaddha V, et al: Perinatal outcome following fetal chest shunt insertion for pleural efusion. Ultrasound Obstet Gynecol 36:58,o2010 FETAL MOVEMENTS............................ 331 FETAL BREATHING .............................. 333 CONTRACTION STRESS TESTING.................. 334 NONSTRESS TESTS .............................. 334 ACOUSTIC STIMULATION TESTS ................... 337 BIOPHYSICAL PROFILE.......................... 337 AMNIONIC FLUID VOLUME....................... 339 DOPPLERVELOCIMETRY......................... 339 ANTENATAL TESTING SUMMARY.................. 340 The rate of the oetal heart is subject to considerable variations, which aords us a airy reliable means of judging as to the well-being of the child. As a general rule, its lie should be considered in danger when the heart-beats all below 100 or exceed 160. -J. Whitridge Williams (1903)


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Obstentrics_Williams. -J. Whitridge Williams (1903) More than 100 years ago, the approach to fetal assessment was rather primitive. Since that time, and especially since the 1970s, technology to evaluate the health of the fetus has advanced remarkably. Techniques employed today to forecast fetal wellbeing focus on fetal biophysical indings that include heart rate, movement, breathing, and amnionic luid production. These indings aid antepartum fetal surveillance to prevent fetal death and avoid unnecessary interventions, which are stated goals of the American College of Obstetricians and Gynecologists and the American Academy of Pediatrics (2017).


Obstentrics_Williams

Obstentrics_Williams. Most fetuses will be healthy, and usually a negativethat is, normal-antepartum test result is highly reassuring, because fetal deaths within 1 week of a normal test are rare. Indeed, negative-predictive values-a true negative test-for most of the tests described are 99.8 percent or higher. In contrast, estimates of the positive-predictive values-a true positive test-for abnormal test results are low and range between 10 and 40 percent. Importantly, fetal surveillance is primarily based on circumstantial evidence. No deinitive randomized clinical trials have been conducted for obvious ethical reasons (American College of Obstetricians and Gynecologists, 2016).


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Obstentrics_Williams. commences as early as 7 weeks' gestation and becomes more sophisticated and coordinated by the end of pregnancy (Sajapala, 2017; Vindla, 1995). Indeed, beyond 8 menstrual weeks, fetal body movements are never absent for periods exceeding 13 minutes (DeVries, 1985). Between 20 and 30 weeks' gestation, general body movements become organized, and the fetus starts to show rest-activity cycles (Sorokin, 1982). Fetal movement maturation continues until approximately 36 weeks, when behavioral states are established in most normal fetuses. Nijhuis and colleagues (1982) described four fetal behavioral states: State 1 F is a quiescent state-quiet sleep-with a narrow oscillatory bandwidth of the fetal heart rate. State 2F includes frequent gross body movements, continuous eye movements, and wider oscillation of the fetal heart rate. This state is analogous to rapid eye movement (EM) or active sleep in the neonate.


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Obstentrics_Williams. State 3F includes continuous eye movements in the absence ofbody movements and no heart rate accelerations. he existence of this state is disputed (Pillai, 1990a). State 4F is one ofvigorous body movement with continuous eye movements and heart rate accelerations. his state corresponds to the awake state in newborns.


Obstentrics_Williams

Obstentrics_Williams. State 4F is one ofvigorous body movement with continuous eye movements and heart rate accelerations. his state corresponds to the awake state in newborns. Fetuses spend most of their time in states IF and 2F. For example, at 38 weeks, 75 percent of time is spent in these two states. hese behavioral states-particularly IF and 2F, which correspond to quiet sleep and active sleep-have been used to develop an increasingly sophisticated understanding offetal behavior. In a study offetal urine production, bladder volumes increased during state IF quiet sleep (Fig. 17-1). Duringstate 2F, the fetal heart rate baseline bandwidth increased appreciably, and bladder volume was signiicantly diminished due to decreased urine production and infrequent fetal voiding. These phenomena were interpreted to represent reduced renal blood flow during active sleep.


Obstentrics_Williams

Obstentrics_Williams. n important determinant of fetal activity appears to be sleep-awake cycles, which are independent of maternal ones. Fetal sleep cyclicity varies from approximately 20 minutes to as much as 75 minutes. In one study, the mean length of the quiet or inactive state for term fetuses was 23 minutes (TimorTritsch, 1978). Patrick and associates (1982) measured gross fetal body movements with real-time sonography for 24-hour periods in 31 normal pregnancies and found the longest period ofinactivity to be 75 minutes. Amnionicluid volume is another important determinant of fetal activity. Sherer and colleagues (1996) assessed the number of fetal movements in 465 pregnancies during biophysical profile testing in relation to amnionic luid volume. hey observed decreased fetal activity with diminished amnionic volumes and suggested that a restricted uterine space might physically limit fetal movements.


Obstentrics_Williams

Obstentrics_Williams. with fetal heart rate (FHR) variation recorded in relation to 1 F or 2F behavior states. State 1 F fetal heart rate has a narrow bandwidth consistent with quiet sleep. State 2F heart rate shows wide oscillation ofthe baseline consistent with active sleep. (Modified with permission from Oosterhof H, vd Stege JG, Lander M, et al: Urine production rate is related to behavioural states in the near term human fetus, Br J Obstet Gynaecol. 1993 Oct;l 00(1 0):920-922.) �E > 400 .. ._ 100 FIGURE 17-2 Graph depicts averages offetal movements counted during 12-hour periods (mean ± SEM). (Data from Sadovsky, 1979a.)


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Obstentrics_Williams. ._ 100 FIGURE 17-2 Graph depicts averages offetal movements counted during 12-hour periods (mean ± SEM). (Data from Sadovsky, 1979a.) Sadovsky and coworkers (1979b) classiied fetal movements into three categories according to both maternal perceptions and independent recordings using piezoelectric sensors. Weak, strong, and rolling movements were described, and their relative contributions to total weekly movements throughout the last half of pregnancy were quantiied. As pregnancy advances, the rate of weak movements decreases, more vigorous movements increase for severalweeks, and then rates of these subside at term. Presumably, declining amnionic luid and space account for diminished activity at term.


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Obstentrics_Williams. Figure 1i7-2 shows fetal movements during the last half ofgestation in 127 pregnancies with normal outcomes. he mean number of weekly movements calculated from 12-hour daily recording periods rose from approximately 200 at 20 weeks' gestation to a maximum of 575 movements at 32 weeks. Fetal movements then declined to an average of 282 at 40 weeks. Normal weekly maternal counts of fetal movements ranged between 50 and 950. Count showed large daily variations, with included counts as low as 4 to 10 per 12-hour period in normal pregnancies. Diminished fetal activity may be a harbinger ofimpending fetal death (Sadovsky, 1973). To quantiy fetal movement, clinical methods include use of a uterine contraction tocodynamometer, visualization with sonography, and maternal subjective perceptions.


Obstentrics_Williams

Obstentrics_Williams. Most, but not all, investigators report excellent correlation between maternally perceived fetal motion and movements documented by instrumentation. For example, Rayburn (1980) found that 80 percent of all movements observed during sonographic monitoring were perceived by the mother. In contrast, Johnson and colleagues (1992) reported that beyond 36 weeks, mothers perceived only 16 percent of fetal body movements. Fetal motions lasting more than 20 seconds were more likely to be identified than shorter episodes. Although several fetal-movement counting protocols have been used, neither the optimal number ofmovements nor the ideal duration for counting them has been defined. For example, in one method, perception of 10 fetal movements in up to 2 hours is considered normal (Moore, 1989). Commonly, women may present in the third trimester complaining of subjectively reduced fetal movement. Harrington and associates (1998) reported that 7 percent of nearly 6800 women presented with a


Obstentrics_Williams

Obstentrics_Williams. Commonly, women may present in the third trimester complaining of subjectively reduced fetal movement. Harrington and associates (1998) reported that 7 percent of nearly 6800 women presented with a complaint of decreased fetal movement. Fetal heart rate monitoring tests were employed if sonographic scans for fetal growth or Doppler velocimetry were abnormal. Pregnancy outcomes for women who complained of decreased fetal movement were not significantly diferent from those for women without this complaint. Scala and colleagues (2015) reported that 6 percent of women at term reported decreased fetal movements at 36 weeks or more. Women with two or more episodes of reduced fetal movements had greater risks of growth-restricted newborns and abnormal Doppler uterine artery low studies. However, stillbirth rates were not increased. Measurement ofthe myocardial performance index did not improve accuracy (Ho, 2017).


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Obstentrics_Williams. Grant and coworkers (1989) performed an unparalleled investigation of maternally perceived fetal movements and pregnancy outcome. More than 68,000 pregnancies were randomly assigned between 28 and 32 weeks' gestation. Women in the fetal movement arm of the study were instructed by specially employed midwives to record the time needed to feel 10 movements each day. his required an average of2.7 hours each day. Women in the control group were informally asked about movements during prenatal visits. Reports of decreased fetal motion were evaluated with tests of fetal well-being. Antepartum death rates for otherwise normal singleton fetuses were similar in the two study groups. Despite the counting policy, most stillborn fetuses were dead by the time the mothers reported for medical attention. Importantly, rather than concluding that maternal perceptions of fetal activity were meaningless, these investigators concluded that informal maternal perceptions were as valuable as formally


Obstentrics_Williams

Obstentrics_Williams. Importantly, rather than concluding that maternal perceptions of fetal activity were meaningless, these investigators concluded that informal maternal perceptions were as valuable as formally recorded fetal movement.


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Obstentrics_Williams. Saastad and associates (2011) reported a total of 1076 women who were randomly assigned to standardized fetal movement counting from gestational week 28 versus no counting. Growth-restricted fetuses were identiied before birth signiicantly more often when fetal movement counting was used. he rate of I-minute Apgar scores :;3 was signiicant reduced (0.4 versus 2.3 percent) when counting was used. Also, Warrander and coworkers (2012) described placental pathology in pregnancies complicated by diminished fetal movements. Decreased movement was associated with various placental abnormalities including infarction.


Obstentrics_Williams

Obstentrics_Williams. After decades of uncertainty as to whether the fetus normally breathes, Dawes and coworkers (1972) showed small inward and outward flows of tracheal fluid in fetal sheep, indicating thoracic movement. These chest wall movements difered from those following birth in that they were discontinuous. Another interesting feature of fetal respiration was paradoxical chest wal movement (Fig. 17-3). In the newborn or adult, the opposite occurs. One interpretation of the paradoxical respiratory motion might be coughing to clear amnionic fluid debris. Although the physiological basis for the


Obstentrics_Williams

Obstentrics_Williams. FIGURE 17-3 Paradoxical chest movement with fetal respiration. During inspiration (A), the chest wall paradoxically col/apses and the abdomen protrudes, whereas during expiration (8), the chest wall expands. (Adapted from Johnson, 1988.) breathing relex is not completely understood, such exchange of amnionic fluid appears to be essential for normal lung development (Chap. 7, p. 133). Dawes (1974) identiied two types of respiratory movements. The irst are gasps or sighs, which occurred at a frequency of 1 to 4 per minute. The second, irregular bursts ofbreathing, occurred at rates up to 240 cycles per minute. hese latter rapid respiratory movements were associated with rapid eye movement. Badalian and associates (1993) studied the maturation of normal fetal breathing using color low and spectral Doppler analysis of nasal fluid low as an index of lung function. hey suggested that fetal respiratory rate declined in conjunction with increased respiratory volume at 33 to 36 weeks and


Obstentrics_Williams

Obstentrics_Williams. spectral Doppler analysis of nasal fluid low as an index of lung function. hey suggested that fetal respiratory rate declined in conjunction with increased respiratory volume at 33 to 36 weeks and coincidental with lung maturation.


Obstentrics_Williams

Obstentrics_Williams. Many investigators have examined fetal breathing movements using sonography to determine whether chest wall movements might reflect fetal health. Several variables in addition to hypoxia were found to afect fetal respiratory movements. These included hypoglycemia, sound stimuli, cigarette smoking, amniocentesis, impending preterm labor, gestational age, the fetal heart rate itself, and labor-during which it is normal for respiration to cease. Because fetal breathing movements are episodic, interpretation of fetal health when respirations are absent may be tenuous. Patrick and associates (1980) performed continuous 24-hour observation using sonography to characterize fetal breathing patterns during the last 10 weeks of pregnancy. A total of 1224 hours of fetal observation in 51 pregnancies were collected, and ).>D C)..=20 Time of day


Obstentrics_Williams

Obstentrics_Williams. C)..=20 Time of day FIGURE 17-4 The percentage of time spent breathing by 11 fetuses at 38 to 39 weeks. There is a significant increase in fetal breathing activity after breakfast. Breathing activity diminished during the day and reached its minimum between 20:00 and 24:00 hours. There was a significant increase in the percentage of time spent breathing between 04:00 and 07:00 hours, when mothers were asleep. (Adapted with permission from Patrick J, Campbell K, Carmichael L, et al: Patterns of human fetal breathing during the last 10 weeks of pregnancy, Obstet Gynecol. 1980 Jul;56(1 ):24-30.)


Obstentrics_Williams

Obstentrics_Williams. Figure 17-4 displays the percentages of time spent breathing near term. Clearly, there is diurnal variation, because breathing substantively diminishes during the night. In addition, breathing activity increases somewhat following maternal meals. Total absence of breathing was observed in some of these normal fetuses for up to 122 minutes, indicating that fetal evaluation to diagnose absent respiratory motion may require long periods of observation. The potential for breathing activity to be an important marker of fetal health is unfulilled because of the multiplicity of factors that normally afect breathing. Most clinical applications have included assessment of other fetal biophysical indices, such as heart rate. As discussed subsequently, fetal breathing has become a component of the biophysical proile.


Obstentrics_Williams

Obstentrics_Williams. As amnionic luid pressure rises with uterine contractions, myometrial pressure exceeds collapsing pressure for vessels coursing through uterine muscle. his ultimately lowers blood flow to the intervillous space. Brief periods of impaired oxygen exchange result, and if utero placental pathology is present, these elicit late fetal heart rate decelerations (Chap. 24, p. 466). Contractions also may produce a pattern of variable decelerations as a result of cord compression, suggesting oligohydramnios, which is often a concomitant of placental insuiciency.


Obstentrics_Williams

Obstentrics_Williams. Ray and colleagues (1972) used this concept in 66 complicated pregnancies and developed the oytocin challenge test, which was later called the contraction stress test. Intravenous oxytocin is used to stimulate contractions, and the criterion for a positive test result, that is, an abnormal result, is uniform repetitive late fetal heart rate decelerations. These reflected the uterine contraction waveform and had an onset at or beyond the contraction acme. Such late decelerations could be the result of uteroplacental insuiciency. In their study, the tests were generally repeated on a weekly basis, and the investigators concluded that negative contraction stress test results, that is, normal results, forecasted fetal health. A major disadvantage is that the average contraction stress test requires 90 minutes to complete.


Obstentrics_Williams

Obstentrics_Williams. To perform the test, the fetal heart rate and uterine contractions are recorded simultaneously with an external monitor. If at least three spontaneous contractions of 40 seconds or longer are present in 10 minutes, no uterine stimulation is necessary (American College of Obstetricians and Gynecologists, 2016). Contractions are induced with either oxytocin or nipple stimulation if there are fewer than three in 10 minutes. For oxytocin use, a dilute intravenous inusion is initiated at a rate of 0.5 mU/min and doubled every 20 minutes until a satisfactory contraction pattern is established (Freeman, 1975). The results of the contraction stress test are interpreted according to the criteria shown in Table


Obstentrics_Williams

Obstentrics_Williams. Nipple stimulation to induce uterine contractions is usually successful for contraction stress testing (Huddleston, 1984). One method involves a woman rubbing one nipple through her clothing for 2 minutes or until a contraction begins. This 2-minute nipple stimulation ideally will induce a pattern of three contractions per 10 minutes. If not, after a 5-minute interval, she is instructed to retry nipple stimulation to achieve the desired pattern. If this is unsuccessful, then dilute oxytocin may be used. Advantages include reduced cost and shortened testing times. Some have reported unpredictable uterine hyperstimulation and fetal distress, whereas others did not find excessive activity to be harmful (Frager, 1987; Schellpfefer, 1985).


Obstentrics_Williams

Obstentrics_Williams. Freeman (1975) and Lee and colleagues (1975) introduced the nonstress test to describe fetal heart rate acceleration in response to fetal movement as a sign of fetal health. This test involved the use of Doppler-detected fetal heart rate acceleration coincident with fetal movements perceived by the mother. By the end of the 1970s, the nons tress test had become the primary method of testing fetal TABLE 17-1. Criteria for Interpretation of the Contraction Stress Test


Obstentrics_Williams

Obstentrics_Williams. Negative: no late or significant variable decelerations Positive: late decelerations following 50% or more of contractions (even if the contraction frequency is fewer than three in 10 minutes) Equivocal-suspicious: intermittent late decelerations or significant variable decelerations Equivocal-hyperstimulatory: fetal heart rate decelerations that occur in the presence of contractions more frequent than every 2 minutes or lasting longer than 90 seconds Unsatisfactory: fewer than three contractions in 10 minutes or an uninterpretable tracing health. he nonstress test was easier to perform, and normal results were used to urther discriminate false-positive contraction stress tests. Simplistically, the nonstress test is primarily a test ofetal condition, and it difers from the contraction stress test, which is considered a test of uteropacentalonction. Currently, nonstress testing is the most widely used primary testing method for assessment of fetal well-being. It has lso been


Obstentrics_Williams

Obstentrics_Williams. stress test, which is considered a test of uteropacentalonction. Currently, nonstress testing is the most widely used primary testing method for assessment of fetal well-being. It has lso been incorporated into the biophysical profile testing system, subsequently discussed.


Obstentrics_Williams

Obstentrics_Williams. Autonomic inluences are mediated by sympathetic or para sympathetic impulses from brainstem centers to normally raise or slow the fetal heart rate. Beat-to-beat variability is also under the control ofthe autonomic nervous system (Matsuura, 1996). Consequently, pathological loss of fetal heart rate acceleration may be seen in conjunction with signiicantly decreased beat to-beat variability (Chap. 24, p. 462). Loss of such reactivity, however, is most commonly associated with sleep cycles. It also rette smoking Oansson, 2005). The nonstress test is based on the hypothesis that the heart rate of a fetus that is not acidemic as a result of hypoxia or to fetal movement. Fetal movements during testing are identi ied by maternal perception and recorded. As hypoxia develops, these fetal heart rate accelerations diminish (Smith, 1988).


Obstentrics_Williams

Obstentrics_Williams. Gestational age inluences acceleration or reactivity ofthe fetal heart rate. Pillai and James (1990b) studied the development of fetal heart rate acceleration patterns during normal pregnancy. The percentage of body movements that is accompanied by accelerations and the amplitude of these accelerations both increase with gestational age (Fig. 17-5). Guinn and colleagues (1998) studied nonstress test results between 25 and 28 weeks' gestation in 188 normal fetuses. Only 70 percent of these normal fetuses demonstrated the required 15 beats per minute (bpm) or more of heart rate acceleration. Lesser degrees of acceleration, that is, 10 bpm, occurred in 90 percent ofthe fetuses.


Obstentrics_Williams

Obstentrics_Williams. The National Institute of Child Health and Human Development Fetal Monitoring Workshop defined normal acceleration based on gestational age (Macones, 2008). In fetuses at or beyond 32 weeks' gestation, the acceleration acme is 15 bpm or more above the baseline rate, and the acceleration lasts 15 seconds or longer but less than 2 minutes. Before 32 weeks, normal accelerations are defined as having an acme that is 10 bpm or more above baseline for 10 seconds or longer. Cousins and associates (2012) compared the Workshop criteria recommended before 32 weeks, that is, 10 bpm/10 seconds, with standard 15 bpm/15 seconds criteria in a randomized trial of 143 women. They found no diferences in perinatal outcomes. ):J=20


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Obstentrics_Williams. ):J=20 FIGURE 17-5 Percentage offetuses tlith at least one acceleration of 15 bpm sustained for 15 seconds concurrent with fetal movement. (Redrawn from Pillai M, James 0: The development offetal heart rate patterns during normal pregnancy, Obstet Gynecol. 1990 Nov;76(5 Pt 1):812-816.)


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Obstentrics_Williams. Criteria to define normal nonstress test results difer. They vary regarding the number, amplitude, and duration of accelerations and the test duration. he definition recommended by the American College of Obstetricians and Gynecologists (2016) requires two or more accelerations peaking at 15 bpm or more above baseline, each lasting 15 seconds or more, and all occurring within 20 minutes of beginning the test (Fig. 17-6). It is also recommended that accelerations with or without fetal movements be accepted, and that a 40-minute or longer tracing-to account for fetal sleep cycles-should be performed before concluding that fetal reactivity is insuicient. Miller and coworkers (1996b) reviewed outcomes in fetuses with nons tress tests considered as nonreactive because there was only one acceleration. hey concluded


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Obstentrics_Williams. FIGURE 17-6 Reactive nonstress test. In the upper panel, notice the increase offetal heart rate by more than 15 beats/min for longer than 15 seconds following fetal movements, which are indicated by the vertical marks (lower panen. that one acceleration was just as reliable as two in predicting healthy fetal status. Although a normal number and amplitude of accelerations seems to reflect fetal well-being, their absence does 60 not invariably predict fetal compromise. Indeed, some investigators have reported 90-percent or higher false-positive rates (Devoe, 1986). Because healthy fetuses may not move for periods of up to 75 minutes, some have considered that a longer duration of nonstress testing might increase the positive-predictive value of an abnormal, that is, nonreactive, test (Brown, 1981). In this scheme, either the test became reactive during a period up to 80 minutes or the test remained nonreactive for 120 minutes, which indicated that the fetus was very ill.


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Obstentrics_Williams. Not only do deinitions of normal nonstress test results difer, but the reproducibility ofinterpretations is problematic (Hage, 1985). Thus, although nons tress testing is popular, the reliability of test interpretation needs improvement. Based on the foregoing, an abnormal nons tress test is not always ominous and can be seen with a sleeping fetus. Also, an abnormal test can revert to normal as the fetal condition changes, such as the example shown in Figure 17-7. Importantly, a normal nonstress test can become abnormal if the fetal condition deteriorates.


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Obstentrics_Williams. Figure 17-7. Importantly, a normal nonstress test can become abnormal if the fetal condition deteriorates. There are abnormal patterns that reliably forecast severe fetal jeopardy (Fig. 17-8). Devoe and coworkers (1985) concluded that nonstress tests that were nonreactive for 90 minutes were almost invariably-93 percent-associated with significant perinatal pathology. Hammacher and coworkers (1968) described tracings with what they termed a silent oscillatoy pattern that he considered dangerous. his pattern consisted of a fetal heart rate baseline that oscillated less than 5 bpm and presumably indicated absent acceleration and beat-to-beat variability.


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Obstentrics_Williams. Visser and associates (1980) described a terminal cardiotocoram, which included: (1) baseline oscillation ofless than 5 bpm, (2) absent accelerations, and (3) late decelerations with spontaneous uterine contractions. hese results were similar to experiences from Parkland Hospital in which absence of accelerations during an 80-minute recording period in 27 fetuses was associated consistently with evidence of uteroplacental pathology (Leveno, 1983). he latter included fetal-growth restriction in 75ipercent, oligohydramnios in 80 percent, fetal acidemia in 40 percent, meconium in 30 percent, and placental infarction in 93 percent.


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Obstentrics_Williams. FIGURE 17-7 Two antepartum fetal heart rate (FHR) tracings in a 28-week pregnant woman with diabetic ketoacidosis. A. FHR tracing (upper panel) and accompanying contraction tracing (second panen. Tracing, obtained during maternal and fetal acidemia, shows absence of accelerations, diminished variability, and late decelerations with weak spontaneous contractions. B. Fetal heart rate tracing shows return of normal accelerations and variability of the fetal heart rate following correction of maternal acidemia.


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Obstentrics_Williams. Set originally rather arbitrarily at 7 days, the interval between tests appears to have been shortened as experience evolved with nonstress testing. According to the American College of Obstetricians and Gynecologists (2016), more frequent testing is advocated by some investigators for women with postterm pregnancy, multifetal gestation, pregestational diabetes, fetalgrowth restriction, or pregnancy hypertension. In these circumstances, some investigators perform twice-weekly tests, with additional testing completed for maternal or fetal deterioration regardless of the time elapsed since the last test. Others perform nonstress tests daily or even more frequently, such as with severe preeclampsia remote from term.


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Obstentrics_Williams. Fetal movements commonly produce heart rate decelerations. Timor-Tritsch and associates (1978) reported this during nonstress testing in half to two thirds of tracings, depending on the vigor of the fetal motion. This high incidence of decelerations inevitably makes interpretation of their signiicance problematic. Indeed, Meis and coworkers (1986) reported that variable fetal TOCO=IT. FIGURE 17-8 Nonreactive nonstress test (left side of tracing) followed by contraction stress test showing mild, late decelerations (right side of tracing). Cesarean delivery was performed, and the severely acidemic fetus could not be resuscitated.


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Obstentrics_Williams. heart rate decelerations during nonstress tests were not a sign of fetal compromise. he American College of Obstetricians and Gynecologists (2016) has concluded that variable decelerations, if nonrepetitive and brief-less than 30 seconds-do not indicate fetal compromise or the need for obstetrical intervention. In contrast, repetitive variable decelerations-at least three in 20 minutes-even if mild, have been associated with a greater risk of cesarean delivery for fetal distress. Decelerations lasting 1 minute or longer have been reported to have an even worse prognosis (Bourgeois, 1984; Druzin, 1981; Pazos, 1982).


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Obstentrics_Williams. Hoskins and associates (1991) attempted to reine interpretation of testing that shows variable decelerations by adding sonographic estimation of amnionic luid volume. The incidence of cesarean delivery for intrapartum fetal distress progressively rose concurrently with the severity of variable decelerations and decline of amnionic luid volume. Severe variable decelerations during a nonstress test plus an amnionic luid index (AFI) ;5 em resulted in a 75-percent cesarean delivery rate. Fetal distress in labor, however, also frequently developed in those pregnancies with variable decelerations but with normal amounts of amnionic luid. Similar results were reported by Grubb and Paul (1992).


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Obstentrics_Williams. Smith and associates (1987) performed a detailed analysis of the causes of fetal death within 7 days of normal nons tress tests. The most common indication for testing was postterm pregnancy. he mean interval between testing and death was 4 days, with a range of 1 to 7 days. he single most common autopsy inding was meconium aspiration, oten associated with some type of umbilical cord abnormality. They concluded that an acute asphyxial insult had provoked fetal gasping. hey also concluded that nonstress testing was inadequate to preclude such an acute asphyxial event and that other biophysical characteristics might be beneicial. Importantly, assessment of amnionic luid volume was considered valuable. Other ascribed frequent causes of fetal death included intrauterine infection, abnormal cord position, malformations, and placental abruption.


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Obstentrics_Williams. Loud external sounds have been used to startle the fetus and thereby provoke heart rate acceleration-an acoustic stimulation nonstress test. A commercially available acoustic stimulator is positioned on the maternal abdomen, and a stimulus of 1 to 2 seconds is applied (Eller, 1995). his may be repeated up to three times for up to 3 seconds (American College of Obstetricians and Gynecologists, 2016). A positive response is deined as the rapid appearance of a qualiYing acceleration following stimulation (Devoe, 2008). In a randomized trial of 113 women undergoing nonstress testing, vibroacoustic stimulation shortened the average time of testing from 24 to 15 minutes (Perez-Delboy, 2002). Similar results were reported by Turitz and coworkers (2012). Laventhal and colleagues (2003) reported that fetal tachyarrhythmia could be provoked with vibroacoustic stimulation.


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Obstentrics_Williams. Manning and colleagues (1980) proposed the combined use of ive fetal biophysical variables as a more accurate means of assessing fetal health than a single element. Typically, these tests require 30 to 60 minutes of examiner time. Shown in Table 1i7-2 are the ive fetal biophysical components assessed: (1) heart rate acceleration, (2) breathing, (3) movements, (4) tone, and (5) amnionic luid volume. Normal variables were assigned a score of 2 each, and abnormal variables were given a score of O. Thus, the highest score possible for a normal fetus is 10. Maternal medications such as narcotics and sedatives can signiicantly lower the score (Kopecky, 2000). Ozkaya and associates (2012) found that biophysical test scores were higher if a test was performed in late evening-20:00 to 22:00 hours-compared with 08:00 to 10:00 hours. TABLE 17-2. Components and Scores for the Biophysical Profile


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Obstentrics_Williams. TABLE 17-2. Components and Scores for the Biophysical Profile Nonstress testa :2 accelerations of : 15 beats/min for : 15 sec within 20-40 min Fetal breathing : 1 episode of rhythmic breathing lasting ::30 sec within 30 min Fetal movement ::3 discrete body or limb movements within 30 min Fetal tone ::1 episode of extremity extension and subsequent retun to fiexion Amnionic fluid A pocket of amnionic fluid that measures at least 2 cm in two volumeb planes perpendicular to each other (2 x 2 cm pocket) o or 1 acceleration within 20-40 min <30 sec of breathing within 30 min <3 discrete movements o extension/flexion events Largest single vertical pocket :;2 cm aMay be omitted if all four sonographic components are normal. bFurther evaluation warranted, regardless of biophysical composite score, if largest vertical amnionic fluid pocket :;2 cm.


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Obstentrics_Williams. bFurther evaluation warranted, regardless of biophysical composite score, if largest vertical amnionic fluid pocket :;2 cm. Manning and colleagues (1987) tested more than 19,000 pregnancies using the biophysical profile interpretation and management shown in Table 17-3. More than 97 percent of the pregnancies tested had normal test results. They reported a false-normal test rate-defined by an antepartum death of a structurally normal fetus-of approximately 1 per 1000. he most common identiiable causes of fetal death after a normal biophysical profile include fetomaternal hemorrhage, umbilical cord accidents, and placental abruption (Dayal, 1999).


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Obstentrics_Williams. Manning and coworkers (1993) published a remarkable description of 493 fetuses in which biophysical scores were performed immediately before measurement of umbilical venous blood pH values obtained via antepartum cordocentesis. Approximately 20 percent of tested fetuses had growth restriction, and the remainder had alloimmune hemolytic anemia. As shown in Figure 17-9, a biophysical score of 0 was almost invariably associated with significant fetal acidemia, whereas a normal score of 8 or 10 was associated with normal pH. An equivocal test result-a score of 6-was a poor predictor of abnormal outcome. As the abnormal score dropped from 2 or 4 down to 0, this decline was a more accurate predictor of abnormal fetal outcome. hus overall, these scores provide poor sensitivity to predict cord blood pH.


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Obstentrics_Williams. Similar studies have substantiated these findings. Salvesen and associates (1993) concluded that the biophysical proile was of limited value in the prediction of fetal pH. Weiner and coworkers (1996) assessed 135 overtly growth-restricted fetuses and came to a similar conclusion. Kaur and colleagues (2008) performed daily biophysical proiles to ascertain the optimal delivery time in 48 growth-restricted preterm fetuses that weighed less than 1000 g. Despite scores of 8 in 27 fetuses and 6 in 13, there were six deaths and 21 acidemic fetuses. Lalor and associates (2008) performed a Cochrane review and concluded that there is insuicient evidence to support the use of the biophysical proile as a fetal well-being test in high-risk pregnancies.


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Obstentrics_Williams. Because the biophysical proile is labor intensive and requires a person trained in sonography, Clark and coworkers (1989) used an abbreviated biophysical proile as a irst-line screening test in 2628 singleton pregnancies. Speciically, a vibroacoustic nons tress test was performed twice weekly and combined with TABLE 17-3. Interpretation of Biophysical Profile Score 10 Normal, nonasphyxiated fetus 8/10 (Normal AFV) Normal, nonasphyxiated fetus 8/8 (NST not done) 8/10 (Decreased AFV) Chronic fetal asphyxia suspected 6 Possible fetal asphyxia o to 2 Almost certain fetal asphyxia If amnionic fluid volume abnormal, deliver If normal fluid at >36 weeks with favorable cervix, deliver If repeat test :;6, deliver If repeat test >6, observe and repeat per protocol Repeat testing same day; if biophysical profile score :;6, deliver Deliver AFV = amnionic fluid volume; NST = nonstress test.


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Obstentrics_Williams. If repeat test >6, observe and repeat per protocol Repeat testing same day; if biophysical profile score :;6, deliver Deliver AFV = amnionic fluid volume; NST = nonstress test. Reproduced with permission from Manning FA, Morrison I, Harman CR, et al: Fetal assessment based on fetal biophysical profile scoring: experience in 19,221 referred high-risk pregnancies. II. An analysis of false-negative fetal deaths, Am J Obstet Gynecol. 1987 Oct;157(4 Pt 1 ):880-884. I. ):J0 downstream impedance (Chap. 10, p. 213). For growth 7.30 7.25 0E:J E:J= 7.20 7.10 7.05 FIGURE 17-9 Mean umbilical vein pH (±2 SD) obtained by cordocentesis in relation to fetal biophysical profile score category. (Data from Manning, 1993.) API determination for which �5 cm was considered abnormal (Chap. 11, p. 230). his abbreviated biophysical proile required approximately 10 minutes to perform, and they concluded that it was a superb antepartum surveillance method because there were no unexpected fetal deaths.


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Obstentrics_Williams. Nageotte and colleagues (1994) also combined biweely nons tress tests with the AFI and considered measures �5 cm to be abnormal. They performed 17,429 modiied biophysical proiles in 2774 women and concluded that such testing was an excellent fetal surveillance tool. Miller and associates (1996a) reported results with more than 54,000 modiied biophysical profiles performed in 15,400 high-risk pregnancies. They described a false-negative rate of 0.8 per 1000 and a falsepositive rate of 1.5 percent. The American College of Obstetricians and Gynecologists (2016) has concluded that the modiied biophysical proile test is as predictive of fetal well-being as other approaches to biophysical fetal surveillance.


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Obstentrics_Williams. he importance of amnionic fluid volume estimation is indicated by its inclusion into virtually all schemes in which fetal health is assessed (Ff0en, 2008). This is based on the rationale that diminished utero placental perfusion may lead to lower fetal renal blood low, decreased urine production, and ultimately, oligohydramnios (Chap. 11, p. 231). The American College of Obstetricians and Gynecologists (2016) concludes that data available from randomized trials indicate that the use of the deepest vertical pocket measurement, as opposed to the AFI, to diagnose oligohydramnios is associated with a reduction in unnecessary interventions without an increase in adverse perinatal outcomes (Nabhan, 2008; Reddy, 2014).


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Obstentrics_Williams. restricted fetuses, several fetal vascular circuits including the umbilical artery, middle cerebral artery, and ductus venosus have been evaluated as diagnostic tools for fetal well-being (Chap. 44, p. 854). Maternal uterine artery Doppler velocimetry has also been assessed as a modality to predict placental dysfunction, with the goal to balance stillbirth against the risks of preterm delivery (Ghidini, 2007). Even the efects of sildenail in pregnant sheep have been evaluated using Doppler velocimetry (Alanne, 2017). he rationale is that sildenafil would improve placental blood low in the presence of placental insuiciency. This proved untrue, as sildenail was associated with detrimental efects on fetal cardiovascular dynamics.


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Obstentrics_Williams. Waveforms were irst studied in the umbilical arteries late in pregnancy, and abnormal waveforms correlated with placental villous hypovascularity. Of the small placental arterial channels, 60 to 70 percent need to be obliterated before the umbilical artery Doppler waveform becomes abnormal. Such extensive placental vascular pathology has a major efect on fetal circulation. According to Trudinger (2007), because more than 40 percent of the combined fetal ventricular output is directed to the placenta, obliteration of placental vascular channel increases aterload and leads to fetal hypoxemia. This in turn leads to ventricular dilation and redistribution of middle cerebral artery blood low. Ultimately, pressure rises in the ductus venosus due to afterload in the right side of the fetal heart (Baschat, 2004). Clinically, abnormal Doppler waveforms in the ductus venosus are a late inding in the progression of fetal deterioration due to chronic hypoxemia.


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Obstentrics_Williams. he umbilical artery systolic-diastolic (SID) ratio is considered abnormal if it is >95th percentile for gestational age or if diastolic low is either absent or reversed (Chap. 10, p. 213). Absent or reversed end-diastolic low signiies greater impedance to umbilical artery blood low (Fig. 44-8, p. 854). It is reported to result from poorly vascularized placental villi and is seen in extreme cases of fetal-growth restriction (T odros, 1999). According to Zelop and colleagues (1996), the perinatal mortali ty rate for absent end-diastolic flow was about 10 percent, and for reversed end-diastolic low, it approximated 33 percent. Spinillo and associates (2005) studied neurodevelopmental outcome at 2 years of age in 266 growth-restricted fetuses delivered between 24 and 35 weeks' gestation. Of infants who had shown absent or reversed umbilical artery low, 8 percent had evidence of cerebral palsy compared with 1 percent of those in whom Doppler low had been normal.


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Obstentrics_Williams. Doppler ultrasound of the umbilical artery has been subjected to more extensive assessment with randomized controlled trials than has any previous test of fetal health. Williams and colleagues (2003) randomized 1360 high-risk women to either nons tress testing or Doppler velocimetry. hey found a significantly higher incidence of cesarean delivery for fetal distress in the nonstress test group compared with that for those tested with Doppler velocimetry-8.7 versus 4.6 percent, respectively. One interpretation of this finding is that the nonstress test more frequently identiied fetuses in jeopardy. Conversely, Gonzalez and associates (2007) found that abnormal umbilical artery Doppler indings in a cohort of growth-restricted fetuses were the best predictors of perinatal outcomes.


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Obstentrics_Williams. he utility of umbilical artery Doppler velocimetry was reviewed by the American College of Obstetricians and Gynecologists (2016). They concluded that no beneit has been demonstrated other than in pregnancies with suspected fetal-growth restriction. Similarly, velocimetry has not proved valuable as a screening test for fetal compromise in the general obstetrical population. Various other fetal-maternal Doppler indices have been studied, including the fetal middle cerebral artery and ductus venosus and the uterine arteries. The American College of Obstetricians and Gynecologists (2016) concluded that Doppler investigations of other blood vessels besides the umbilical artery have not been shown to improve perinatal outcome.


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Obstentrics_Williams. As discussed, at this time, Doppler velocimetry interrogation of the middle cerebral artery (MCA) to detect fetal compromise is not recommended. Still, the technology has received particular attention because of observations that the hypoxic fetus attempts brain sparing by reducing cerebrovascular impedance and thus increasing blood flow. Such brain sparing in growthrestricted fetuses has been documented to undergo reversal (Konje, 2001). Investigators reported that 8 of 17 fetuses with this reversal died. Ott and coworkers (1998) randomized 665 women undergoing modified biophysical proile evaluation to either the profile alone or combined with middle cerebral and umbilical artery velocity low assessment. Pregnancy outcomes between these two study groups did not difer significantly.


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Obstentrics_Williams. Middle cerebral artery Doppler velocimetry has proven valuable to detect severe fetal anemia in 165 fetuses with D-antigen alloimmunization. Oepkes and colleagues (2006) prospectively compared serial amniocentesis for measurement of bilirubin levels with Doppler measurement of peak systolic velocity in the middle cerebral artery. These investigators concluded that Doppler could safely replace amniocentesis in the management of alloimmunized pregnancies. And as discussed in Chapter 15 (p. 303), this technique has been reported to be useul for detection and management of fetal anemia of any cause (Moise, 2008).


Obstentrics_Williams

Obstentrics_Williams. Doppler ultrasound has also been used to assess the fetal venous circulation. Bilardo and colleagues (2004) prospectively studied umbilical artery and ductus venosus Doppler velocimetry in 70 growth-restricted fetuses at 26 to 33 weeks' gestation. hey concluded that ductus venosus velocimetry was the best predictor of perinatal outcome. Importantly, negative or reversed low in the ductus venosus was a late finding because these fetuses had already sustained irreversible multiorgan damage due to hypoxemia. Also, gestational age at delivery was a major determinant of perinatal outcome independent of ductus venosus flow. Specifically, 36 percent of growth-restricted fetuses delivered between 26 and 29 weeks' gestation succumbed compared with only 5 percent delivered from 30 to 33 weeks.


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Obstentrics_Williams. Baschat and coworkers (2007) studied 604 growth-restricted fetuses using umbilical artery, middle cerebral artery, and ductus venosus Doppler velocimetry and reached similar conclusions. Speciically, absent or reversed flow in the ductus venosus was associated with profound generalized fetal metabolic collapse. hey too reported that gestational age was a powerful cofactor in ultimate perinatal outcome for growth-restricted fetuses delivered before 30 weeks. Put another way, by the time severely abnormal low is seen in the ductus venosus, it is too late because the fetus is already near death. Conversely, earlier delivery puts the fetus at risk for death due to preterm delivery. Ghidini (2007) concluded that these reports do not support routine use of ductus venosus Doppler in the monitoring of growth-restricted fetuses and recommended further study.


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Obstentrics_Williams. Vascular resistance in the uterine circulation normally decreases in the irst half of pregnancy due to invasion of maternal uterine vessels by trophoblastic tissue (Chap. 5, p. 92). This process can be detected using Doppler flow velocimetry, and uterine artery Doppler may be most helpful in assessing pregnancies at high risk of utero placental insuiciency (Abramowicz, 2008). Persistence or development of high-resistance patterns has been linked to various pregnancy complications (Lees, 2001; Yu, 2005). In a study of 30,519 unselected British women, Smith and colleagues (2007) assessed uterine artery velocimetry at 22 to 24 weeks' gestation. The risk of fetal death before 32 weeks, when associated with abruption, preeclampsia, or fetal-growth restriction, was significantly linked to high-resistance flow. This has led to suggestions for continued research of uterine artery Doppler velocimetry as a screening tool to detect pregnancies at risk for stillbirth (Reddy, 2008). Sciscione and


Obstentrics_Williams

Obstentrics_Williams. flow. This has led to suggestions for continued research of uterine artery Doppler velocimetry as a screening tool to detect pregnancies at risk for stillbirth (Reddy, 2008). Sciscione and Hayes (2009) reviewed the use of uterine artery Doppler flow studies in obstetrical practice. Because standards for the study technique and criteria for an abnormal test are lacking, they noted that uterine artery Doppler studies should not be considered standard practice in either low-or high-risk populations.


Obstentrics_Williams

Obstentrics_Williams. Antenatal forecasts of fetal health have clearly been the focus of intense interest, and several themes emerge. First, despite a continuous evolution of testing options, the precision or eicacy of any given method is limited. Second, the wide range of normal biological fetal variation makes interpretation of test results challenging. Last, despite the invention of increasingly complex testing methods, abnormal results are seldom reliable, prompting many clinicians to use antenatal testing to forecast fetal welness rather than ilness.


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Obstentrics_Williams. Platt and coworkers (1987) reviewed the eicacy of antenatal testing between 1971 and 1985 at Los Angeles County Hospital. During this 15-year period, more than 200,000 pregnancies were managed, and nearly 17,000 of these women underwent antepartum testing of various types. Fetal surveillance rose from < 1 percent of pregnancies in the early 1970s to 15 percent in the mid-1980s. hese authors concluded that such testing was clearly beneicial because the fetal death rate was signiicantly less in the tested high-risk pregnancies compared with the rate in those not tested. he study, however, did not consider other innovations incorporated into practice during those 15 years. Preliminary results from Ghana suggest that nonstress testing may be beneicial in low-resource countries (Lawrence, 2016). In an observational study of 316 pregnancies complicated by gestational hypertension, women undergoing nons tress testing had a nonsignificant decreased risk for stillbirth compared with those not


Obstentrics_Williams

Obstentrics_Williams. In an observational study of 316 pregnancies complicated by gestational hypertension, women undergoing nons tress testing had a nonsignificant decreased risk for stillbirth compared with those not tested-3.6 versus 9.2 percent, respectively.


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Obstentrics_Williams. The beneits of antenatal fetal testing have not been suficiently evaluated in randomized controlled trials according to hacker and Berkelman (1986). This was concluded after reviewing 600 reports, which included only four randomized trials that were not powered to permit detection of important beneits. From their review, Enkin and colleagues (2000) concluded that "despite their widespread use, most tests of fetal well-being should be considered of experimental value only rather than validated clinical tools." nother important and unanswered question is whether antepartum fetal surveillance identiies fetal asphyxia early enough to prevent brain damage. Manning and coworkers (1998) studied the incidence of cerebral palsy in 26,290 high-risk pregnancies managed with serial biophysical proile testing. These outcomes were compared with those of 58,657 low-risk pregnancies in which antepartum testing was not performed. The rate of cerebral palsy was 1.3 per 1000 in tested pregnancies


Obstentrics_Williams

Obstentrics_Williams. proile testing. These outcomes were compared with those of 58,657 low-risk pregnancies in which antepartum testing was not performed. The rate of cerebral palsy was 1.3 per 1000 in tested pregnancies compared with 4.7 per 1000 in untested women. Todd and coworkers (1992) attempted to correlate cognitive development in infants up to age 2 years following either abnormal umbilical artery Doppler velocimetry or nons tress test results. Only abnormal nonstress tests were associated with marginally poorer cognitive outcomes. These investigators concluded that by the time fetal compromise is diagnosed with antenatal testing, fetal damage has already been sustained. Low and associates (2003) reached a similar conclusion.


Obstentrics_Williams

Obstentrics_Williams. According to the American College of Obstetricians and Gynecologists (2016), a normal antepartum fetal test result is , highly reassuring that a stillbirth will not occur within 1 week. This conclusion was reached after an analysis of reports of stillbirth rates associated with the various antepartum fetal heart rate tests (Table 17-4). Note that these results are corrected to remove lethal anomalies and unpredictable catastrophes such TABLE 17-4. Stillbirth Rates within 1 Week of a Normal Antepartum Fetal Surveillance Test Nonstress test 1s.9 5861 Contraction stress test OJ 12,656 Biophysical profile 0.8 44,828 Modified biophysical profile 0.8 54,61s7 aCorrected fot lethal anomalies and unpredictable causes of fetal death such as abruption or cord accident. as placental abruption or cord accidents. The most important consideration in deciding when to begin antepartum testing is the prognosis for neonatal survival.


Obstentrics_Williams

Obstentrics_Williams. as placental abruption or cord accidents. The most important consideration in deciding when to begin antepartum testing is the prognosis for neonatal survival. The severity of maternal disease is another. In general, with most high-risk pregnancies, testing begins by 32 to 34 weeks' gestation. P�egnancies with severe complications might require testing as early as 26 to 28 weeks. he frequency for repeating tests has been arbitrarily set at 7 days, but more frequent testing is often done. Abramowicz JS, Sheiner E: Ultrasound of the placenta: a systemic approach. Part II: function assessment (Doppler). Placenta 29(11):921,o2008 Alanne L, Hofren J, Haapsamo M, et al: Efect of sildenail citrate on fetal central hemodynamics and placental volume blood low during hypoxemia in a chronic sheep model. Abstract No. 25. Presented at the 37th Annual Meeting of the Society for Maternal-Fetal Medicine. January 23-28, 2017


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Obstentrics_Williams. American Academy of Pediatrics and American College of Obstetricians and Gynecologists: Guidelines for perinatal care, 8th ed. Elk Grove Village, AAP,o2017 American College of Obstetricians and Gynecologists: Antepartum fetal surveillance. Practice Bulletin No. 145, July 2014, Reairmed 2016 Badalian 55, Chao CR, Fox HE, et al: Fetal breathing-related nasal fluid flow velocity in uncomplicated pregnancies. Am J Obstet Gynecol 169:563, 1993 Baschat AA: Opinion and review: Doppler application in the delivery timing in the preterm growth-restricted fetus: another step in the right direction. Ultrasound Obstet Gynecol 23: 11o8, 2004 Baschat AA, Cosmi E, Bilardo C, et al: Predictors of neonatal ourcome in earlyonset placental dysfunction. Obstet Gynecol 109:253, 200 Bilardo CM, Wolf H, Stigter RH, et al: Relationship between monitoring parameters and perinatal outcome in severe, early intrauterine growth restriction. Ultrasound Obstet Gynecol 23: 199, 2004


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Obstentrics_Williams. Bilardo CM, Wolf H, Stigter RH, et al: Relationship between monitoring parameters and perinatal outcome in severe, early intrauterine growth restriction. Ultrasound Obstet Gynecol 23: 199, 2004 Bourgeois FJ, Thiagarajah 5, Harbert GM J r: The signiicance of fetal heart rate decelerations during nonstress testing. Am J Obstet Gynecol 150:213, 1984 Brown R, Patrick J: he nonstress test: how long is enough? Am J Obstet Gynecol 141:646, 1981 Clark SL, Sabey P, Jolley K: Nonstress testing with acoustic stimulation and amnionic luid volume assessment: 5973 tests without unexpected fetal death. Am J Obstet Gynecol 160:694, 1989 Cousins LM, Poelder DM, Faron 5, et al: Nonstress testing at ;32.0 weeks' gestation: a randomized trial comparing diferent assessment criteria. Am J Obstet (4):311.e1, 2012 Dawes GS: Breathing before birth in animals and man. An essay in medicine. Physiol Med 290:557, 1974


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Obstentrics_Williams. Dawes GS: Breathing before birth in animals and man. An essay in medicine. Physiol Med 290:557, 1974 Dawes GS, Fox HE, Leduc BM, et al: Respiratory movements and rapid eye movement sleep in the foetal lamb. J Physiol 220: 119, 1972 Dayal AK, Manning FA, Berek DJ, et al: Fetal death after normal biophysical proile score: an eighteen year experience. m J Obstet Gynecol 181:o1231, 1999 Devoe LD: Antenatal fetal assessment: contraction stress test, nonstress test, vibroacoustic stimulation, amniotic fluid volume, biophysical proile, and modified biophysical profile-an overview. Semin Perinatol 32(4):247, 2008 Devoe LD, Castillo A, Sherline DM: The nonstress test as a diagnostic test: a critical reappraisal. Am J Obstet GynecoIo152:1047, 1986 Devoe LD, McKenzie J, Searle NS, et al: Clinical sequelae of the extended nonstress test. m J Obstet GynecoIo151:1074, 1985 DeVries J1, Visser GH, Prechd NF: The emergence of fetal behavior. II. Quantitative aspects. Early Hum Dev 12:99, 1985


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Obstentrics_Williams. DeVries J1, Visser GH, Prechd NF: The emergence of fetal behavior. II. Quantitative aspects. Early Hum Dev 12:99, 1985 Druzin ML, Gratacos J, Keegan A, et al: Antepartum fetal heart rate testing, 7. The signiicance of fetal bradycardia. m J Obstet Gynecol 139: 194, 1981 Eller DP, Scardo JA, Dillon E, et al: Distance from an intrauterine hydrophone as a factor afecting intrauterine sound pressure levels produced by the vibroacoustic stimulation test. Am J Obstet Gynecol 173:523, 1995 Enkin M, Keirse MJ, Renfrew M, et al: A Guide to Efective Care in Pregnancy and Childbirth, 3rd ed. New York, Oxford University Press, 2000 Frager NB, Miyazaki FS: Intrauterine monitoring of contractions during breast stimulation. Obstet Gynecol 69:767, 1987 Freeman RK: The use of the oxytocin challenge test for antepartum clinical evaluation of utero placental respiratory function. Am J Obstet Gynecol 121:481, 1975 Fr0en JF, Tviet


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Obstentrics_Williams. Freeman RK: The use of the oxytocin challenge test for antepartum clinical evaluation of utero placental respiratory function. Am J Obstet Gynecol 121:481, 1975 Fr0en JF, Tviet JV, Saastad E, et a1: Management of decreased fetal movements. Semin ,r2008 Ghidini A: Doppler of the ductus venosus in severe preterm fetal growth restriction. A test in search of a purpose? Obstet Gynecol 109:250, 200 Gonzalez JM, Stamilio OM, Ural S, et al: Relationship between abnormal fetal testing and adverse perinatal outcomes in intrauterine growth restriction. Am J Obstet Gynecol 196:e48, 2007 Grant A, Elbourne 0, Valentin L, et al: Routine formal fetal movement counting and risk of antepartum late death in normally formed singletons. Lancet 2:345, 1989 Grubb OK, Paul RH: Amnionic luid index and prolonged antepartum fetal heart rate decelerations. Obstet Gynecol 79:558, 1992


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Obstentrics_Williams. Grubb OK, Paul RH: Amnionic luid index and prolonged antepartum fetal heart rate decelerations. Obstet Gynecol 79:558, 1992 Guinn DA, Kimberlin KF, Wigton TR, et al: Fetal heart rate characteristics at 25 to 28 weeks gestation. Am J Perinatol 15:507, 1998 Hage ML: Interpretation of nonstress tests. Am J Obstet Gynecol 153:490, 1985 Hammacher K, Huter A, Bokelmann J, et al: Foetal heart frequency and perinatal condition of the foetus and newborn. Gynaecologia 166:349, 1968 Harrington K, Thompson 0, Jorden L, et al: Obstetric outcomes in women who present with a reduction in fetal movements in the third trimester of pregnancy. J Perinat Med 26:77, 1998 Ho 0, Wang J, Homann Y, et a1: Use of the myocardial performance index in decreased fetal movement assessment: a case-control study. Fetal Diagn Ther June 15, 2017 [Epub ahead of print]


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Obstentrics_Williams. Ho 0, Wang J, Homann Y, et a1: Use of the myocardial performance index in decreased fetal movement assessment: a case-control study. Fetal Diagn Ther June 15, 2017 [Epub ahead of print] Hoskins IA, Frieden FJ, Young BK: Variable decelerations in reactive nonstress tests with decreased amnionic luid index predict fetal compromise. Am J Obstet Gynecol 165: 1094, 1991 Huddleston JF, Surlif JG, Robinson 0: Contraction stress test by intermittent nipple stimulation. Obstet Gynecol 63:669, 1984 Jansson LM, DiPietro J, Elko A: Fetal response to matenal methadone administration. Am J Obstet Gynecol 193:611,2005 Johnson MJ, Paine LL, Mulder HH, et al: Population diferences of fetal biophysical and behavioral characteristics. Am J Obstet Gynecol 166: 138, 1992 Kaur S, Picconi JL, Chadha R, et al: Biophysical proile in the treatment of intrauterine growth-restricted fetuses who weigh < 1000 g. Am J Obstet Gynecol 199:264.el, 2008


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Obstentrics_Williams. Kaur S, Picconi JL, Chadha R, et al: Biophysical proile in the treatment of intrauterine growth-restricted fetuses who weigh < 1000 g. Am J Obstet Gynecol 199:264.el, 2008 Konje JC, Bell SC, Taylor DT: Abnormal Doppler velocimetry and blood low volume in the middle cerebral artery in very severe intrauterine growth restriction: is the occurrence of reversal of compensatory low too late? BJOG 108:9 3,r2001 Kopecky EA, Ryan ML, Barrett JFR, et a1: Fetal response to maternally administered morphine. Am J Obstet Gynecol 183:424,r2000 Lalor JG, Fawole B, Alirevic Z, et al: Biophysical proile for fetal assessment in high risk pregnancies. Cochrane Database Syst Rev I :CD000038, 2008 Laventhal NT, Dildy GA III, Belfort MA: Fetal tachyarrhythmia associated with vibroacoustic stimulation. Obstet Gynecol 101: 116, 2003


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Obstentrics_Williams. Lawrence ER, Quarshie EL, Lewis KF, et al: Introduction of cardiotocograph monitoring improves birth outcomes in women with preeclampsia in Ghana. IntJ Gynaecol Obstet 132(1):103,r2016 Lee CY, DiLoreto Pc, O'Lane JM: A study of fetal heart rate acceleration patterns. Obstet GynecoIr45:142, Lees C, Parra M, Missfelder-Lobos H, et al: Individualized risk assessment for adverse pregnancy outcome by uterine artery Doppler at 23 weeks. Obstet Gynecol 98:369, 2001 Leveno KJ, Williams ML, DePalma RT, et al: Perinatal outcome in the absence of antepartum fetal heart rate acceleration. Obstet Gynecol 61 :347, 1983 Low JA, Killen H, Derrick EJ: Antepartum fetal asphyxia in the preterm preg nancy. Am J Obstet Gynecol 188:461, 2003 Macones GA, Hankins GO, Spong CY, et al: The 2008 National Institute of Child Health and Human Development workshop report on electronic fetal monitoring: update on deinitions, interpretation, and research guidelines. Obstet Gynecol 112:661, 2008


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Obstentrics_Williams. Manning FA, Bondagji N, Harman CR, et 1: Fetal assessment based on fetal biophysical proile scoring VIII: the incidence of cerebral palsy in tested and untested perinates. Am J Obstet Gynecol 178:696, 1998 Manning FA, Morrison 1, Harman CR, et a1: Fetal assessment based on fetal biophysical proile scoring: experience in 19,221 referred high-risk pregnancies, 2. n analysis of false-negative fetal deaths. Am J Obstet Gynecol 15 :880, 1987 Manning FA, Platt LD, Sipos L: Antepartum fetal evaluation: development of a fetal biophysical proile. Am J Obstet Gynecol , 1980 Manning FA, Snijders R, Harman CR, et al: Fetal biophysical proile score, VI. Correlation with antepartum umbilical venous fetal pH. Am J Obstet GynecoIr169:755, 1993 Matsuura M, Murata Y, Hirano T, et al: he efects of developing autonomous nervous system on FHR variabilities determined by the power spectral analysis. Am J Obstet Gynecol 174:380, 1996


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Obstentrics_Williams. Matsuura M, Murata Y, Hirano T, et al: he efects of developing autonomous nervous system on FHR variabilities determined by the power spectral analysis. Am J Obstet Gynecol 174:380, 1996 Meis PJ, Ureda JR, Swain M, et a1: Variable decelerations during nonstress tests are not a sign of fetal compromise. Am J Obstet Gynecol 154:586, 1986 Miller DA, Rabello YA, Paul RH: The modiied biophysical proile: antepar tum testing in the 1990s. Am J Obstet GynecoIr174:812, 1996a Miller F, Miller 0, Paul R, et al: Is one fetal heart rate acceleration during a nons tress test as reliable as two in predicting fetal status? Am J Obstet 4:337, 1996b Moise KJ Jr: he usefulness of middle cerebral artery Doppler assessment in the treatment of the fetus at risk for anemia. Am J Obstet Gynecol 198: 161. e1,r2008 Moore TR, Piaquadio K: A prospective evaluation of fetal movement screening to reduce the incidence of antepartum fetal death. Am J Obstet Gynecol 160: 1075, 1989


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Obstentrics_Williams. Moore TR, Piaquadio K: A prospective evaluation of fetal movement screening to reduce the incidence of antepartum fetal death. Am J Obstet Gynecol 160: 1075, 1989 Nabhan AF, Abdelmoula YA: Amniotic luid index versus single deepest vertical pocket as a screening test for preventing adverse pregnancy outcome. Cochran Database Syst Rev 3:CD006593, 2008


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Obstentrics_Williams. Nageotte MP, Towers CV, Asrat T, et al: Perinatal outcome with the modiied biophysical proile. Am J Obstet Gynecol 170: 2, 1994 Nijhuis JG, Prechtl HF, Martin CB J r, et al: Are there behavioural states in the human fetus? Early Hum Dev 6: , 1982 Oepkes 0, Seaward PG, andenbussche FP, et al: Doppler ultrasonography versus amniocentesis to predict fetal anemia. N Engl J Med 355: 156, 2006 Oosterhof H, vd Stege JG, Lander M, et al: Urine production rate is related to behavioural states in the near term human fetus. BJOG 100:920, 1993 Ott ('], Mora G, Arias F, et al: Comparison of the modiied biophysical proile to a "new" biophysical proile incorporating the middle cerebral artery to umbilical artery velocity low systolic/diastolic ratio. Am J Obstet Gynecol 178:1346,r1998 Ozkaya E, Baser E, Cinar M, et al: Does diurnal rhythm have an impact on fetal biophysical profile? J Maten Fetal Neonatal Med 25(4):335, 2012 Patrick J, Campbell K, Carmichael L, et al: Patterns of gross fetal body


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Obstentrics_Williams. E, Cinar M, et al: Does diurnal rhythm have an impact on fetal biophysical profile? J Maten Fetal Neonatal Med 25(4):335, 2012 Patrick J, Campbell K, Carmichael L, et al: Patterns of gross fetal body movements over 24-hour observation intervals during the last 10 weeks of pregnancy. Am J Obstet Gynecol 142:363, 1982 Patrick J, Campbell K, Carmichael L, et al: Patterns of human fetal breathing during the last 10 weeks of pregnancy. Obstet Gynecol 56:24, 1980 Pazos R, Vuolo K, Aladjem S, et al: Association of spontaneous fetal heart rate decelerations during antepartum nonstress testing and intrauterine growth retardation. Am J Obstet Gynecol 144:574, 1982 Perez-Oelboy A, Weiss J, Michels A, et al: A randomized trial of vibroacoustic stimulation for antenatal fetal testing. Am J Obstet Gynecol 187:S 146, 2002 Pillai M, James 0: Behavioural states in normal mature human fetuses. Arch Dis Child 65:39, 1990a Pillai M, James 0: The development of fetal heart rate patterns during normal


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Obstentrics_Williams. Gynecol 187:S 146, 2002 Pillai M, James 0: Behavioural states in normal mature human fetuses. Arch Dis Child 65:39, 1990a Pillai M, James 0: The development of fetal heart rate patterns during normal pregnancy. Obstet Gynecol 6:812, 1990b Platt LD, Paul RH, Phelan J, et al: Fifteen years of experience with antepartum fetal testing. Am J Obstet Gynecol 156:1509, 198 Ray M, Freeman R, Pine S, et al: Clinical experience with the oxytocin challenge test. Am J Obstet Gynecol 1r14: 1, 2 Raybun WF: Clinical signiicance of perceptible fetal motion. Am J Obstet Gynecol 138:210, 1980 Reddy UM, Abuhamad Z, Levine 0, et al: Fetal imaging: executive summary of a joint Eunice Kennedy Shriver National Institute of Child Health and Human Development, Sociery for Maternal-Fetal Medicine, American Institute of Ultrasound in Medicine, American College of Obstetricians and Gynecologists, American College of Radiology, Society for Pediatric Radiology, and Society of Radiologists in Ultrasound Fetal


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Obstentrics_Williams. of Ultrasound in Medicine, American College of Obstetricians and Gynecologists, American College of Radiology, Society for Pediatric Radiology, and Society of Radiologists in Ultrasound Fetal Imaging Workshop. Obstet Gynecol 123(5):10 0,r2014 Reddy UM, Filly A, Copel JA, et al: Prenatal imaging: ultrasonography and magnetic resonance imaging. Obstet Gynecol 112(1):145,r2008 Saastad E, Winje BA, Stray Penderson B, et al: Fetal movement counting improved identiication of fetal growth restriction and perinatal outcomesa multi-centre, randomized, controlled trial. PLoS One 6(12):e28482, 2011 Sadovsky E, Evron S, Weinstein 0: Daily fetal movement recording in normal pregnancy. Riv Obstet Ginecol Practica Med Perinatal 59:395, J 9a Sadovsky E, Laufer N, Allen JW: he incidence of diferent types of fetal movement during pregnancy. BJOG 86:10, 1979b Sadovsky E, Yafe H: Daily fetal movement recording and fetal prognosis. Obstet Gynecol 41:845,r1973


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Obstentrics_Williams. Sajapala S, AboElIail MA, Kanenshi K, et a1: 40 ultrasound study of fetal movement early in the second trimester of pregnancy. J Perinat Med 45(6):737,r2017 Salvesen DR, Freeman J, Brudenell JM, et al: Prediction of fetal acidemia in pregnancies complicated by maternal diabetes by biophysical scoring and fetal heart rate monitoring. BJOG , 1993 Scala C, Bhide A, Familiari A, et al: Number of episodes of reduced fetal movement at term: association with adverse perinatal outcome. Am J Obstet Gynecol 213(5):678.el, 2015 Schell pfefer MA, Hoyle 0, Johnson JWC: Antepartum uterine hypercontractiliry secondary to nipple stimulation. Obstet Gynecol 65:588, 1985 Sciscione AC, Hayes EJ: Uterine artery Doppler low studies in obstetric practice. Am J Obstet Gynecol 20r1(2):121, 2009 Sherer DM, Spong CY, Ghidini A, et al: In preterm fetuses decreased amniotic luid volume is associated with decreased fetal movements. Am J Obstet Gynecol 174:344, 1996


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Obstentrics_Williams. Sherer DM, Spong CY, Ghidini A, et al: In preterm fetuses decreased amniotic luid volume is associated with decreased fetal movements. Am J Obstet Gynecol 174:344, 1996 Smith CV, Nguyen HN, Kovacs B, et al: Fetal death following antepartum fetal heart rate testing: a review of 65 cases. Obstet Gynecol 70: 18, 1987 Smith Gc, Yu CK, Papageorghiou AT, et al: Maternal uterine artery Doppler low velocimetry and the risk of stillbirth. Obstet Gynecol 109: 144, 2007 Smith JH, Anand KJ, Cotes PM, et al: Antenatal fetal heart rate variation in relation to the respiratory and metabolic status of the compromised human fetus. BJOG 95:980, 1988 Sorokin Y, Bottoms SF, Dierker CJ, et al: he clustering of fetal heart rate changes and fetal movements in pregnancies berween 20 and 30 weeks gestation. Am J Obstet Gynecol 143:952, 1982


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Obstentrics_Williams. Sorokin Y, Bottoms SF, Dierker CJ, et al: he clustering of fetal heart rate changes and fetal movements in pregnancies berween 20 and 30 weeks gestation. Am J Obstet Gynecol 143:952, 1982 Spinillo A, Montanari L, Bergante C, et al: Prognostic value of umbilical artery Doppler studies in unselected preterm deliveries. Obstet Gynecol 105:613, 2005 hacker SB, Berkelman RL: Assessing the diagnostic accuracy and eicacy of selected antepartum fetal surveillance techniques. Obstet Gynecol Surv 41:121,r1986 Timor-Tritsch IE, Dierker LJ, Hertz RH, et al: Studies of antepartum behavioral state in the human fetus at term. Am J Obstet Gynecol 132:524, 1978 Todd AL, Tridinger BJ, Cole MJ, et al: Antenatal tests of fetal welfare and development at age 2 years. Am J Obstet Gynecol 167:66, 1992 Todros T, Sciarrone A, Piccoli E, et al: Umbilical Doppler waveforms and placental villous angiogenesis in pregnancies complicated by fetal growth restriction. Obstet Gynecol 93:499, 1999


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Obstentrics_Williams. Todros T, Sciarrone A, Piccoli E, et al: Umbilical Doppler waveforms and placental villous angiogenesis in pregnancies complicated by fetal growth restriction. Obstet Gynecol 93:499, 1999 Trudinger B: Doppler: more or less? Ultrasound Obstet Gynecol29 (3):243, 2007 Turitz AL, Bastek JA, Sam mel MD, et al: Can vibroacoustic stimulation improve the eiciency of a tertiary care antenatal testing unit? J Matern Fetal Neonatal Med 25(12):2645,r2012 VindJa S, James 0: Fetal behavior s a test oHetl well-being. BJOG 102:597, 1995 Visser GHA, Redman CWG, Huisjes HJ, et al: Nonstressed antepartum heart rate monitoring: implications of decelerations after spontaneous contractions. Am J Obstet Gynecol 138:429, 1980 Warrander LK, Batra G, Bernatavicius G, et al: Maternal perception of reduced fetal movements is associated with altered placental structure and function. PLoS One 7(4):e34851, 2012


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Obstentrics_Williams. Warrander LK, Batra G, Bernatavicius G, et al: Maternal perception of reduced fetal movements is associated with altered placental structure and function. PLoS One 7(4):e34851, 2012 Weiner Z, Divon MY, Katz N, et al: Multi-variant analysis of antepartum fetal test in predicting neonatal outcome of growth retarded fetuses. Am J Obstet Gynecol 174:338, 1996 Williams KP, Farquharson OF, Bebbington M, et al: Screening for fetal wellbeing in a high-risk pregnant population comparing the nonstress test with umbilical artery Doppler velocimetry: a randomized controlled clinical trial. Am J Obstet Gynecol 188: 1366, 2003 Yu CK, Smith GC, Papageorghiou AT, et al: An integrated model for the prediction of preeclampsia Llsing maternal factors and uterine artery Doppler velocimetry in unselected low-risk women. Am J Obstet Gynecol 193:429,r2005


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Obstentrics_Williams. Zelop CM, Richardson OK, Hefner LJ: Outcomes of severely abnormal umbilical artery Doppler velocimetry in structurally normal singleton fetuses. Obstet Gynecol 8 :434, 1996 NOMENCLATUREe. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 346 FIRST-TRIMESTER SPONTANEOUS ABORTION .e.e.e347 SPONTANEOUS ABORTION CLINICAL CLASSIFICATION .e348 RECURRENT MISCARRIAGE ..e......... ....e.. ..e352 MIDTRIMESTER ABORTIONe. . . . . . . . . . . . . . . . . . . . . . . 353 CERVICAL INSUFFICIENCY ..e..e..... . .... ....... 354 INDUCED ABORTION .e.. ....e.e...e..e...e...e...e. 357 FIRST-TRIMESTER ABORTION METHODS ..........e. 358 SECOND-TRIMESTER ABORTION METHODS .. .... . 362


Obstentrics_Williams

Obstentrics_Williams. INDUCED ABORTION .e.. ....e.e...e..e...e...e...e. 357 FIRST-TRIMESTER ABORTION METHODS ..........e. 358 SECOND-TRIMESTER ABORTION METHODS .. .... . 362 In the eary months of pregnancy spontaneous expulsion of the ovum is neary always preceded by the death of the oetus. For this reason the consideration of the aetioloy of abortion practicaly resolves itsef into determining the cause of oetal death. In the later months, on the other han, the oetus is frequenty born alive, and other actors must be looked or to explain its expulsion. -J. Whitridge Williams (1903)


Obstentrics_Williams

Obstentrics_Williams. -J. Whitridge Williams (1903) In early pregnancy, miscarriage is a common event. Most early losses stem from genetic abnormalities or yet unidentified reasons. Thus, the opportunity for prevention is currently small. Women with later miscarriage or with recurrent miscarriage more likely have a repetitive cause that may be modiied. In contrast to these spontaneous losses, pregnancy termination may be elected. For both induced abortion and miscarriage, management has evolved to include surgical or medical options, and providers should have an understanding of these techniques and their potential complications.


Obstentrics_Williams

Obstentrics_Williams. Abortion is defined as the spontaneous or induced termination of pregnancy before fetal viability. It thus is appropriate that miscarriage and abortion are terms used interchangeably. However, popular use of abortion by laypersons implies intended pregnancy termination, and many prefer miscarriage for spontaneous loss. In contrast, induced abortion describes surgical or medical termination of a live fetus that has not reached viability.


Obstentrics_Williams

Obstentrics_Williams. Terms used to define fetal viability and thus an abortus vary among authoritative organizations. The National Center for Health Statistics, the Centers for Disease Control and Prevention, and the World Health Organization all deine abortion as pregnancy termination or loss before 20 weeks' gestation or with a fetus delivered weighing <500 g. hese criteria, however, are somewhat contradictory because the mean birthweight of a 20-week fetus is 320 g, whereas 500 g is the mean for 22 to 23 weeks (Moore, 1977). Further confusion may derive from criteria set by state laws that deine abortion even more widely.


Obstentrics_Williams

Obstentrics_Williams. Technological developments have added to current abortion terminology. For example, precise measurement of serum human chorionic gonadotropin (hCG) concentrations can identiY extremely early pregnancies. Also, transvaginal sonography allows greater inspection of failed pregnancies, but recommendations vary as to terms for: (1) early conceptions in which no products are seen sonographically, (2) pregnancies that display a gestational sac but no embryo, and (3) those in which a dead embryo is seen (Kolte, 2015; Silver, 2011). Further, incongruity exists for the term eary pregnancy loss itsel. Currently, the American College of Obstetricians and Gynecologists (2017 c) deines this as a nonviable, intrauterine pregnancy (IUP) with either an empty gestational sac or a ges activity within the irst 126' weeks of gestation. Of other clini cal terms, spontaneous abortion includes threatened, inevitable, incomplete, complete, and missed abortion. Septic abortion is used to further classiy any of


Obstentrics_Williams

Obstentrics_Williams. 126' weeks of gestation. Of other clini cal terms, spontaneous abortion includes threatened, inevitable, incomplete, complete, and missed abortion. Septic abortion is used to further classiy any of these that are complicated further by infection. Recurrent pregnancy loss is variably deined but is meant to identiy women with repetitive miscarriage.


Obstentrics_Williams

Obstentrics_Williams. pic gestations. he term pregnancy of unknown location (PUL) confirmed sonographic location. In this context, ive categories are proposed for early pregnancies: definite ectopic pregnancy, probable ectopic, PUL, probable IUP, and definite IUP (Barn hart, 2011). Diagnostic and management options for ectopic gestation are described in Chapter 19 (p. 373).


Obstentrics_Williams

Obstentrics_Williams. More than 80 percent of spontaneous abortions occur within the irst 12 weeks of gestation. With irst-trimester losses, demise of the embryo or fetus nearly always precedes spontaneous expulsion. Death is usually accompanied by hemorrhage into the decidua basalis. This is followed by adjacent tissue necrosis that stimulates uterine contractions and expulsion. An intact gestational sac is usually filled with luid. An anembryonic miscarriage contains no identifiable embryonic elements. Less accurately, the term blighted ovum may be used (Silver, 201l). The others are embyonic miscarriages, which often display a developmental abnormality of the embryo, fetus, yolk sac, and, at times, the placenta. In contrast, in later pregnancy losses, the fetus usually does not die before expulsion, and other sources for abortion are sought.


Obstentrics_Williams

Obstentrics_Williams. Rates for miscarriage vary according to the study population. In pregnancies aged 5 to 20 weeks' gestation, the incidence ranges from 11 to 22 percent and is higher in earlier weeks (Ammon Avalos, 2012). To evaluate rates starting at conception, Wilcox and colleagues (1988) studied 221 healthy women trying to conceive through 707 menstrual cycles and found a miscarriage rate of 31 percent. This study found that two thirds of these losses are early and clinicaly silent. Currently, certain factors are known to inluence clinicaly apparent miscarriage. However, it is unknown if these same factors also afect clinically silent pregnancy loss.


Obstentrics_Williams

Obstentrics_Williams. Of all miscarriages, approximately half are euploid abortions, that is, carrying a normal chromosomal complement. The other half has a chromosomal abnormality. Initially determined by tissue karyotyping, this percentage appears to persist even when implementing newer cytogenetic techniques Qenderny, 2014). Notably, the American College of Obstetricians and Gynecologists (20 16d) does not recommend routine use of chromosomal microarray testing of irst-trimester fetal tissues. However, these organizations, and the American Society for Reproduc tive Medicine (2012), recognize its value if cytogenetic analysis alters future care. Both abortion and chromosomal anomaly rates decline with advancing gestational age (Ammon Avalos, 2012; Eiben, 1990).


Obstentrics_Williams

Obstentrics_Williams. Both abortion and chromosomal anomaly rates decline with advancing gestational age (Ammon Avalos, 2012; Eiben, 1990). Kajii and associates (1980) noted that 75 percent of chromo somally abnormal abortions occurred by 8 weeks' gestation. Of chromosomal abnormalities, 95 percent are caused by maternal gametogenesis errors, and 5 percent by paternal errors Qacobs, 1980). Most common abnormalities are trisomy, found in 50 to 60 percent; monosomy X, in 9 to 13 percent; and triploidy, in 11 to 12 percent (Eiben, 1980; Jenderny, 2014). Trisomies typically result from isolated nondisjunction, rates of which rise with maternal age (Bow§, 1975). Trisomies of chromosomes 13, 16, 18, 21, and 22 are most common. In contrast, balanced structural chromosomal rearrangements may originate from either parent and are found in 2 to 4 percent of couples with recurrent pregnancy loss.


Obstentrics_Williams

Obstentrics_Williams. Monosomy X (45,X) is the single most frequent specific chro mosomal abnormality. his is Turner syndrome, which usually results in abortion, but liveborn females are described in Chap ter 13 (p. 259). Conversely, autosomal monosomy is rare and incompatible with life. Triploidy is often associated with hydropic or molar placental degeneration (Chap. 20, p. 389). The fetus within a partial hydatidiform mole frequently aborts early, and the few carried longer are all grossly deformed. Advanced maternal and paternal ages do not increase the incidence of triploidy. Tetraploid fetuses most often abort early in gestation, and they are rarely liveborn. In chromosomally normal pregnancy losses, maternal influences play a role. The causes of euploid abortions are poorly understood, but various medical disorders, environmental conditions, and developmental abnormalities have been implicated.


Obstentrics_Williams

Obstentrics_Williams. Euploid pregnancies abort later than aneuploid ones. Specifically, the rate of euploid abortion peaks at approximately 13 weeks (Kajii, 1980). In addition, the incidence of euploid abortion rises dramatically after maternal age exceeds 35 years (Stein, 1980). Some common viruses, bacteria, and parasites that invade the normal human can infect the fetoplacental unit by blood-borne transmission. Others may infect locally through genitourinary infection or colonization. However, despite the numerous infections acquired in pregnancy and discussed in Chapters 64 and 65, these uncommonly cause early abortion.


Obstentrics_Williams

Obstentrics_Williams. Some disorders are possibly linked with higher rates of early pregnancy loss and are discussed in their respective chapters. Prominent risks are associated with poorly controlled diabetes mellitus, obesity, thyroid disease, and systemic lupus erythematosus. In these and others, inflammatory mediators may be an underlying theme (Kalagiri, 2016; Sjaarda, 2017). Although thrombophilias were initially linked to various pregnancy outcomes, most putative associations have been refuted (American College of Obstetricians and Gynecologists (2017e).


Obstentrics_Williams

Obstentrics_Williams. herapeutic doses of radiation are undeniably abortifacient. Doses that cause abortion are not precisely known, but suggested parameters are found in Chapter 46 (p. 906). Similarly, the efects of chemotherapy exposure in causing abortion are not well deined (Chap. 12, p. 242). Particularly worrisome are women with an ongoing pregnancy after early exposure to methotrexate, described later (p. 361). Of cancer survivors, those who were treated with abdominopelvic radiotherapy or chemotherapy may later be at greater risk for miscarriage, as discussed in Chapter 63 (p. 1192).


Obstentrics_Williams

Obstentrics_Williams. The risk of miscarriage caused by surgery is not well studied. But, as discussed in Chapter 46 (p. 901), uncomplicated surgical procedures performed during early pregnancy are unlikely to increase the abortion risk (Mazze, 1989). Of indications, ovarian tumors can generally be resected without inciting miscarriage. An important exception involves early removal of the corpus luteum or the ovary in which it resides. If performed before 10 weeks' gestation, supplemental progesterone should be given, and supplementation is enumerated in Chapter 63 (p.i1198). Trauma seldom causes first-trimester miscarriage, and although Parkland Hospital is a busy trauma center, this is an infrequent association. Major trauma-especially abdominalcan cause fetal loss, but is more likely as pregnancy advances (Chap. 47, p. 925).


Obstentrics_Williams

Obstentrics_Williams. Sole deficiency of one nutrient or moderate deiciency of all does not appear to increase risks for abortion. Even in extreme cases-for example, hyperemesis gravidarum-abortion is rare. Dietary quality may play a role, as miscarriage risk may be reduced in women who consume a diet rich in fruits, vegetables, whole grains, vegetable oils, and ish (Gaskins, 2015). With regard to maternal weight, underweight is not associated with a greater miscarriage risk (Balsells, 2016). However, as noted in Chapter 48 (p. 938), obesity does raise pregnancy loss rates. Lifestyle choices reputed to be associated with a higher miscarriage risk are most often related to chronic and especially heavy use oflegal substances. he most commonly used is alcohol, with its potent teratogenic efects discussed in Chapter 12 (p. 239). That said, an increased miscarriage risk is only seen with regular or heavy use (Avalos, 2014; Feodor Nilsson, 2014).


Obstentrics_Williams

Obstentrics_Williams. Approximately 10 percent of pregnant women admit to cigarette smoking (Centers for Disease Control and Prevention, 2016). It seems intuitive that cigarettes could cause early pregnancy loss (Pineles, 2014). Adverse efects of illicit drugs areidiscussed in Chapter 12 (p. 249).