1. PRINCIPLES OF FETAL MONITORING MohdHanafiRamlee

2. I’M SORRY, I CAN’T INTERPRET SOME OF THE PICTURE HERE!!!BUT I’LL TRY MY BEST!!!

3. AIMS OF FETAL MONITORING Assessment of fetal well-being especially in high-risk mother Assessments of fetal growth Identification of fetal abnormalities and condition in all stages of pregnancy Determination of gestational period To ensure a safe delivery

4. Antenatal monitoring Labour monitoring

7. Mother should gain 0.5 kg/week during 2nd and early 3rd trimester  then, the rate of weight gain is plateaus off

8. ↓: possibilities of IUGR, persistent nausea and vomiting or forced dieting

10. The centimeters should roughly correspond to the period of gestation

11. ↑: polyhydramnios

13. FETAL KICK CHART Commonest methods – Cardiff ‘count to ten’ Start count at 9am every morning Record the time taken for baby to move 10 times Normal fetal activity-little variation in time taken ↓ fetal activity [fetal compromise] - delay in time taken Benefit: detection of fetal compromise, more easier and cheap Limitation: Maternal anxiety is common, unsure of movement, is a crude guide and sometimes inconsistent

14. A FAVOURABLE FETAL MOVEMENT CHART Day Patient’s Name Time (am/pm))

15. AN UNFAVOURABLE FETAL MOVEMENT CHART Day Patient’s Name Time (am/pm))

18. DIAGNOSTIC ULTRASOUND SCAN - 2 dimensional map of content of uterus. - Image constantly updated in real time and fetal cardiac and other movement can be studied. - < 12 weeks usage oftransvaginaltransducer. - > 12 weeks usage of abdominal transducer. - Good image depend on operator skill. - Disadvantages : Bio effects on cells, inducing heating.

19. transvaginal -TRANDUCER - abdominal

20. Age Assessment Early Problems Measurement Amniotic Fluid Volume Symmetry Umbilical Cord Abnormalities Growth Weight Invasive Procedure Anatomy Location Morphology

21. EARLY PREGNANCY PROBLEMS - transvaginal ultrasound role in diagnosis of disorder in early pregnancy. E.g. miscarriage - fetus present, absent fetal heart E.g. ectopic pregnancy - absent of gestational sac within uterus

22. FETAL MEASUREMENTS

23. FETAL MEASUREMENT Common = relatively ‘spared’ in growth restriction Sensitive = organ that are sensitive to changes to any factor that cause IUGR [liver/spleen]

24. CROWN-RUMP LENGTH

25. CROWN-RUMP LENGTH Geatational sac Yolk sac Fetal pole

26. BPD, HC LENGTH Biparietal diameter Head circumference

27. BPD, HC LENGTH

28. FEMUR LENGTH Femur length

29. FEMUR LENGTH

30. ABDOMINAL CIRCUMFERENCE Abdominal Circumference

31. GESTATIONAL AGE ASSESSMENT CRL/BPD  these measurements are plotted on the normogram Predictions of gestational age by ultrasound scan before 20 weeks is more accurate than predictions from last menstrual period. Measurements are done at least 2 week apart Measurements are plotted in centile-charts against a normogram

32. MEASUREMENT ON FETAL GROWTH CHART

33. Consistent growth of Small fetus

34. Slowed growth— fetal compromise

35. FETAL SYMMETRY ↑HC: Hydrocephalus ↓HC: Microcephaly ↓FL: constitutional short stature, achondroplasia ↑AC: Diabetic pregnancy, ↓AC: triploidy / trisomy 18 Asymmetry: IUGR

36. PLACENTA Transvaginal scan: if the placenta covers the internal os major placenta praevia Mid pregnancy scan  low-lying placenta 3rd pregnancy scan  minor placenta praevia

37. OTHERS CONDITION Amniotic Fluid scan: commonly base on AFI [if <2cm: Oligohydramnious, >7cm: Polyhdramnious] Umbilical Cord: scan with colourdoppler [Nuchal displacement: common event associated with fetal distress] Invasive procedure: amniocentesis, chorionvillus sampling, cordocentesis, fetal bladder shunt therapy, fetoscopy and endoscope.

39. AIMS OF ROUTINE ULTRASOUND SCAN

40. Magnetic Resonance Imaging: useful when i) US images are not diagnostic or ii) suboptimal because of maternal obesity

42. MRI

44. Remove: Fetal swallowing and blood

48. Recorded in waveform pattern :

49. Systolic - blood velocity speeds up.

51. Doppler Uterine Artery Waveforms Assessment of uterine artery waveforms at 24th weeks’ gestation. Benefits: Even at absence of risk factors, severely abnormal waveforms identify 75% of pregnancies at risk of adverse neonatal outcome in early 3rd trimester. Limitations: Less effective at prediction of later problems.

57. Sensitive

59. <110 bpm = bradycardia

61. Modified by :

62. Fetal sleep states and activity.

63. Hypoxia.

64. Fetal infection.

65. Drugs e.g. opioids and hypnotics (reduce baseline variability).

66. Baseline variability – 8 bpm and 2-6 times in a minute.

67. Principles of Fetal Monitoring 52

69. Within 20 – 30 minutes CTG, 2 or more accelerations present define as reactive trace.

72. Principles of Fetal Monitoring 55

73. Principles of Fetal Monitoring 56

74. Principles of Fetal Monitoring 57

76. Meconium Stained Liquor Sign of fetal compromise Can only be diagnose during labour, or only after the membrane have been ruptured May be due to Intestinal hurry Spontaneous dilatation of anal sphincters Manifestations of foetal hypoxia.

77. OTHERS MONITORING MohdHanafiRamlee

80. Sickledex test – sickle cell disease.

81. Maternal blood group/rhesus antibodies.

82. Maternal serum virology – CMV/toxoplasmosis/Rubella/parvovirus

84. maternal serum alpha-fetoprotein (AFP) screening for neural tube defects (NTDs) and Down syndrome.

85. Increase level - fetal open NTDs.

87. human beta-chorionic gonadotropin

88. unconjugatedoestriol.

90. THANK YOU FOR YOUR ATTENTION