diagnositcs day 2 review
TRANSCRIPT
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Diagnostic Tests
Sandy Warner RNC-OB, MSNCarrie Hallett- Voss, RNFA
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NST - Non Stress Test
Evaluation of FHR pattern in the absence of regular contractions to determine fetal oxygenation, neurological and cardiac function
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Non Stress Test (NST)
NST became popular as primary surveillance in mid 1970’s due to simplicity and shorter testing
Currently a reactive pattern is defined as 2 accelerations in 20 minutes that reach 15bpm or greater above BLFHR and lasts 15 seconds or greater
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NST Definition
Reactive NST indicates less than 1% chance of fetal death within 1 week unless there is a catastrophic event
Accelerations may occur either spontaneously or in association with fetal movement
NST done to determine the adequacy of fetal oxygenation and (CNS) autonomic function
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Non Stress Test: Benefits to patient
non-invasive easy, inexpensive, fast no known contraindications good screening test
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Non Stress Test (NST) Accelerations indicate intact
neurological functioning between the fetal CNS and the fetal heart
Pathway may be disrupted by: Fetal sleep Fetal hypoxia Drugs (BTMS, ETOH, beta blockers, muscle
relaxants, & CNS depressants) Congenital fetal anomalies
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Non Stress Test (NST) 50% of fetuses will be reactive by
26-28 weeks 85% of fetuses will be reactive by
28-32 weeks KEYPOINT:
Once fetus has had a reactive tracing (15 X 15) the same reactivity is
expected in further NSTs.
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Indications for NST for High Risk Conditions
high risk for utero-placental insufficiency (smokers, HTN, diabetes, autoimmune disease)
post dates motor vehicle accident (MVA) previous stillbirth IUGR decreased fetal movement isoimmunization if other tests suggest fetal compromise routine
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Reactive Non Stress Test
Arrows above from pushing the MARK buttonIndicating mother’s perception of fetal movement
FM and Accelerations 15 X 15
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NST Regimen
1986 study by Boehm showed that by increasing NST to 2 times a week, the corrected stillbirth rate dropped from 6.1 /1000 to 1.9/1000 after a reactive NST
Twice a week for high risk (post dates, HTN, IUGR, IDDM)
Once q week for other risk conditions If condition no longer exists, e.g. decreased
fetal movement, continued testing is not required
Same day evaluation for reporting of decreased fetal movement
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Non Reactive NST Not necessarily an ominous sign, rather it
does indicate the need for further testing. May be followed by a BPP or a CST If initially non-reactive, prolonging the
period of evaluation usually allows a change in the fetal status and it becomes reactive
Occurs more often in the preterm fetus < 32 weeks due to immature ANS
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Non Reactive NST Non Reactive NST
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NST
Non reactive NST with good variability probably not an indication for delivery rather, could be related to fetal adaptation to stress
Non Stress Test (NST)
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Vibroaccoustic Stimulation (VAS)
Artificial acoustic stimulation
Done after 25 wks gestation when fetus can hear
After 10 minutes of baseline and no accelerations, place the artificial larynx on the maternal abdomen over the fetal head
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Vibroaccoustic Stimulation
Provide 5-10 sec stimulation near fetal head, wait one minute
If no acceleration repeat cycle for a total of three times
if non-reactive after 40 minutes, proceed with further evaluation
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Vibroaccoustic Stimulation
Fetuses 28 weeks or greater respond to VAS with a consistent increase in heart rate.
Observed changes are greater as term is approached.
Can be used during version to get breech to move from midline spine to lateral spine
Use to startle the fetus to release cord
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Contraction Stress Test
A method of observing the response of the FHR to the stress of uterine contractionsA FHR response to 3 spontaneous or induced uterine contractions in 10 minutes may occur:
• Spontaneously• Use of nipple stimulation• Use of Pitocin
The desired result: Negative CST (no late decelerations)
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Interpretation: CST Negative: No late or significant variable
decelerations are identified in response to 3 or more contractions lasting at least 40 seconds in a 10 minute window.
Positive: Late decelerations are identified with 50% or more of contractions even if the contraction frequency is less than 3 in 10 minutes.
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Interpretation: CST Suspicious : (Equivocal) inconsistent or
occasional late decelerations with less than 50% of contractions. Repeat in 24 hrs.
Tachysystole: Contractions closer than Q2min, or lasting longer than 90 sec, or > 5 contractions in 10 minutes. Repeat in 24 hrs.
Unsatisfactory: the quality of the tracing is inadequate for interpretation or adequate uterine contractions were not achieved.
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Limitations of CST
• 30% false positive == unnecessary premature intervention
• conduct in L+D or adjacent area• more expensive, time consuming• must observe after test until
uterine activity has returned to baseline activity level
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Tachysystole of uterusToo many UC. Rising restingtonus.
Positive CST
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Key Points for Contraction Stress Test
CST now used less frequentlyUterine contractions produce a reduction in blood flow to the intervillous spaces in the placentaA fetus with inadequate placental reserves demonstrates late decelerations in response to hypoxia
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Ultrasound
Developed in WWII with submarines
Diagnostic use since 1950s
Definition: transmission of sound waves to investigate an object
(Kline-Fath & Bitters, 2007)
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Ultrasound
Advantages: Inexpensive Noninvasive High degree of patient acceptance Yields much information
(Kline-Fath & Bitters, 2007)
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Ultrasound Indications Estimation of fetal age
Earlier U/S performed, more accurate Viability Evaluation of fetal growth Location of placenta Fetal presentation in 3rd trimester or
with multiples Anomalies Assessment of amniotic fluid volume
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Ultrasound con’t Numerous studies show positive effect on
maternal bonding with ultrasound experience
3D U/S especially helpful in facial anomalies
Nuchal lucency and nasal bone Used in combination with maternal serum levels to
assess for chromosomal abnormalities (Kline-Fath & Bitters, 2007)
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Amniotic Fluid Index (AFI)
AFI = amount of amniotic fluid measured in largest pocket in each quadrant ( sum of 4 quadrants)
Normal = 9-10 cm Borderline = 5-8cm Oligohydramnios < 5cm Polyhydramnios > 25cm
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Biophysical Profile (BPP) “Intrauterine Apgar Score” Combines ultrasound and NST Fetal activities observed result
from complex processes that are controlled by the CNS
Activities that are first to develop are last to disappear when asphyxia occurs
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1. Reactive NST (within 1 hour of ultrasound portion of test)
2. Amniotic Fluid: at least one deepest vertical pocket > 2cm
3. Movement- at least three episodes of gross body movement within a 30 minute period
Five Parameters of Biophysical Profile
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Five Parameters of Biophysical Profile
4. Tone- at least one episode of flexion and extension of an extremity within a 30 minute period
5. Fetal Breathing Motions- at least 30 seconds within a 30 minute period
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Scoring the BPP
• 2 points for each of the criteria met
• 0 points if the criteria is not met
• reported as: 0/10, 2/10, 4/10, 6/10, 8/10, or 10/10
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Interpretation of BPP
• Anytime a (DVP) deep vertical pocket ≤ 2cm, further evaluation is warranted
• score 8/10 (excluding oligo) or 10/10: normal
• score 6/10 : equivocal, repeat within 24 hours
• score 0/10, 2/10, 4/10: delivery is indicated
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Keypoints
A deteriorating fetus will lose in this order:
-Reactivity-Fetal breathing
movements-Tone-Movement
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Doppler Studies
Definition: Non-invasive study of the blood flow in
the fetus and the placenta
Studies the blood flow of the umbilical cord
More recently may use to look at blood flow in the cerebral artery
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Keypoints of Doppler Flow Studies
Doppler waveform analysis can allow identification of a jeopardized fetus before compromises occur.
Umbilical artery observed for flow Ratio number used to measure flow 3.5 in normal, can also be intermittently absent or
absent Reverse diastolic flow is ominous
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More Keypoints of Doppler Flow Studies
The change in frequency is called the “Doppler Shift”
This shift is computer analyzed and displayed as a velocity waveform
The frequency of the echoes changes during the systolic and diastolic components of the cardiac cycle
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Amniocentesis
Trans-abdominal needle aspiration of 10-20 ml of amniotic fluid for lab analysis
Done under ultrasound
Requires sterile technique and time out
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Amniocentesis
Indications: Genetic R/O infection Fetal lung maturity Assess for bilirubin with hemolytic
incompatibility
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Amniocentesis
Timing: Early – performed between 11-14 wks
Significantly higher pregnancy loss Post procedure fluid loss
2nd trimester – performed between 15-20 wks
Usually for genetic screening
3rd trimester Usually for fetal lung maturity
(Gilbert, 4th edition, pg 93)
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Amnioreduction
Reduces amount of amniotic fluid around fetus
Procedure like amniocentesis only with tubing to suction canister or stopcock
Done to relieve maternal symptoms or with twin to twin transfusion syndrome
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Amnioreduction
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Fetal Vesicoamniotic Shunt Procedure done for
bladder outlet obstruction
Most common cause is a posterior urethral valve
Predominantly in males Can cause bladder to
lose tone Hydronephrosis Hydroureter Can lead to permanent
damage if not treated by 20 weeks gestation
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Fetal Vesicoamniotic Shunt
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Fetal Vesicoamniotic Shunt - echotip needle in bladder
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Fetal Vesicoamniotic Shunt – post shunt placement and decompression of bladder
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Bilateral Hydronephrosis (enlarged kidneys)
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Cordocentesis / Fetal Blood Transfusion
Blood Transfusion for anemia
How much blood is given?
Graph is used correlating the hematocrit of donor blood to the hematocrit of the fetus to determine donor blood volume to be given
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Cordocentesis / Fetal Blood Transfusion
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Fetal MRI Superior soft tissue contrast test Does not use radiation Used for fetal brain, spinal deformities,
lesions, masses Also can assess placental and cord
malformations Also used to measure lung volume
Research still continuing for PPROM pts (Kline-Fath & Bitters, 2007)
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Fetal MRI Con’t Not recommended in first trimester
(no documented studies on harm from heat or sound, but not recommended)
Not used routinely, only after U/S not able to detect
Contrast dye not recommended
Informed consent (Kline-Fath & Bitters, 2007)
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Fetal Echocardiogram Timing: between 18-22 weeks Indications:
Family history congenital heart defects Maternal diabetes Drug exposure Teratogenic exposure Chromosomal abnormalities Non-immune hydrops Maternal PKU Fetal arrhythmias
Queenan, Hobbins & Spong (4th edition, 2007)
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