IN THE NAME OF GOD IN THE NAME OF GOD

BIOPHYSICAL PROFILEBIOPHYSICAL PROFILE

B.P.PB.P.P

In 1980 Manning and colleagues introduced BPP for evaluation of the fetus.

BPP is a noninvasive test that predicts the presence or absence of fetal asphyxia

BBP combines data from two sources: -FHR monitoring -Ultrasound

B.P.P Fetal Heart Reactivity (NST) Fetal Breathing Movement Fetal Movement Fetal Tone Amniotic Fluid Volume

Pathophysiology

Tissue hypoxia stimulates the aortic & carotid chemoreceptors (extremely high metabolism) cardiac output redistribution away from fetal kidneys & viscera &limbs in favor of the brain, heart , placenta and adrenal glands (redistribution)

Cont. Chronic hypoxia olygohyramnios:

1-decreased renal perfusion&^^ ADH 2-^^ fetal lung resorption 3-^^fetal swallowing 4-decreased fluid in amniotic space ^^pressure umbilical cord decreased perfusion

progression of hypoxia/ acidemia cerebral edema and heart failure poor perinatal prognosis high mortality & morbidity

Fetal Central Nervous System Centers

Fetal Tone / 7.5 to 8.5 w cortex (sub cortical area)

Fetal Movements /9 w cortex nuclei

Fetal Breathing Movement /21 w Ventral surface of the 4th ventricle

Nonstress test /24-26 w post. hypothalamus , medulla

Emberyo

genesis

Hypoxia

Hypoxia cellular function change (special neuronal tissue)

CONT.

The centers regulating fetal movement have a higher threshold than those for fetal breathing or FHR accelerations; the fetal tone center has the highest threshold.

Heart rate reactivity would be the first parameter to be alerted, and fetal tone the last.

When the NST is reactive , the presence of fetal acidemia is R/O.

The BPP highly correlates with the ante partum fetal umbilical venous cord PH level.

Heart rate reactivity & fetal breathing are inhibited at PH <7.20

Fetal body movements & fetal tones disappear at PH <7.10

Variable Score 2 Score 0

Fetal Breathing Movements

1 or more episodes lasting at least 30” /30`

No episodes of 30” duration

Fetal Movements

3 or more gross body or limb movements in 30`

2 or fewer body or limb movements in 30`

Fetal Tone

At least 1 episode of motion of a limb (from extension to flexion) or trunk /opening& closing of hand

Slow extension or partial flexion /hand remains open

Fetal reactivity

2 or more accelerations of15 beats per minute lasting 15” in 20`

No or less than 2 accelerations FHR in 40`

Amniotic fluid volume

At least 1 pocket measuring 2 cm

Largest pocket of amniotic fluid<1cm

There are 2 scoring systems: -The original BPP described by Manning

et al. 10/10 -Vintzileos et al in 1983 proposed

another scoring system ,which gave intermediate scores (0,1,2), and also included placental grading as one of the biophysical variables.12/12

More than 90% of tests that are normal are completed within the first 4’,and average testing time is less than 8’.

Some have suggested using fetal acoustic stimulation to shorten the period for testing.

Fetal breathing Fetal breathing movements should be considered present only if they are continuous for at least 20”-30”, with breath-to-breath intervals of less than 6”.

hiccups also count as breathing movements Scoring: ->1 episode of “breathing”>30”in 30’=2 points -No episode of “breathing”>30” in 30’=0 points

CONT.

Fetal breathing movements & fetal activities are reduced during maternal fasting

The unusual presence of CONTINUOUS MONOTONOUS fetal breathing, with complete absence of all other behavior for an extended period , may indicate acidosis, especially in diabetic fetus

Body Movement Gross motor activities :

-body/ trunk roll -spine flexion or extension -gross limb movement

Fine-motor activities: -eye movement -sucking /swallowing

Scoring: ->3 movements in 30’=2 points -<3 movements in 30’=0 points

Fetal tone

Active limb movement -Flexion extension flexion -Hand opens and closes

Scoring: ->1 episodes in 30’=2 points - 0 episodes in 30’=0 points

Amniotic fluid (AF) volume

Largest AF pocket is found : in vertical & transverse measurement

Different than 4 quadrant Amniotic Fluid Index/AFI

Use color Doppler for AF assessment - help avoid measurement of cord in AF pockets

Careful attention to transducer pressure is required to avoid a false diagnosis of oligohydramnios

Scoring: ->1 pocket of fluid > 2cm × 2cm=2 points -No pocket of fluid > 2cm × 2cm=o points

CONT.

The BPP is a combination of acute &chronic markers reflecting fetal well-being

acute : -fetal heart rate reactivity -fetal breathing movements -fetal movements -fetal tone

chronic: amniotic fluid volume

#3 wks for significant oligohydramnios to develop

Cont. The only score that is allowed to stand after the

US variables have been evaluated is 8/8. A score of “6/8” is not a BPS. When the 4 US variables are performed first

(modification), if any of these is absent, NST (only 10%) must be performed before the BPS is complete, and the score will be x/10.

Modification reduced the need for NST in 95 percent of cases and the average testing time per patient without reducing the predictive value of the test.

Modified B.P.P The modified biophysical profile was developed to

simplify the examination and reduce the time necessary to complete testing .

It is consisting of an NST & AFI The rate of stillbirth within one week of a normal test is

the same as with the full BPS, 0.8 per 1000 women tested.

The AFI is derived by adding the largest vertically measured pocket from each uterine quadrant.

Oligohydramnios is defined as an AFI of less than 6/ 5cm.

If either NST or the AFI is abnormal, a complete BPP or a OCT is performed

RESULT INTERPRETATION RISK OF ASPHYXIA

RECOMMENDED TREARMENT /MORTALITY

10/10 nonasphyxiated 0% Conservative 1/1000

8/8 or10 (N.AF)

nonasphyxiated 0%

8/10 (ANL. AF)

Chronic compensated asphyxia 5-10% If mature ( >37w ) , deliver If immature , serial testing (twice weekly) 89/1000

6/10 (N.AF) Acute asphyxia possible/equivocal test(repeat testing immediately, before assigning final

value. If score is 6/10,then 10/10,in 2 continues 30’ periods, manage as 10/10)

Varied If mature ( >37w ) , deliver If immature ,repeat test in 24h & If < 6/10, deliver 50/1000

6/10 (ANL. AF)

Chronic asphyxia &possible acute >10% If > 32 weeks, deliver If < 32 wk, test daily >50/1000

4/10 (N.AF) Acute asphyxia likely 36% If > 32 weeks, deliver If < 32 wk, test daily 115/1000

4/10 (ANL.AF)

Chronic asphyxia &acute asphyxia >36% If > 26 wk , deliver >115/1000

2/10 (N.AF) Acute asphyxia almost certain 73% If > 26wk , deliver 220/1000

0/10 Score acute asphyxia virtually certain

100% Deliver immediately by cesarean section600/1000

Cont.

A normal BPP normal BPP (of >8) is considered predictive of a nonacidotic a nonacidotic fetus.

The presence of oligohydromnios in either scoring system is considered abnormal, because reduced AF reduced AF puts the fetus at risk of risk of cord compression cord compression , death, or adverse perinatal outcomes, regardless the scores of the other biophysical parameters.