The biophysical profile (BPP) is a non-stress test used to assess fetal well-being. It involves ultrasound evaluation of fetal movement, breathing, muscle tone, and amniotic fluid volume, with scores ranging from 0-10. A score of 8 or higher is considered normal while lower scores indicate increased risk of fetal distress within a week. The BPP was developed in the 1980s and provides information about acute and chronic aspects of fetal oxygenation, with abnormal results requiring more frequent testing or delivery. Accuracy depends on proper administration and interpretation, and while observational studies support its use in high-risk pregnancies, randomized trials have not found clear benefits over non-stress testing alone.

1. Biophysical
profile
Dr. Waleed Tawfik

2.  overview of the biophysical profile
 Fetal physiology related to biophysical testing
 Ultrasound equipment,
 testing indications,
 biophysical test procedures,
 scoring criteria,
 test interpretation, and management based on
test results.
 Factor affecting test results
Objectives

3. The goals of antepartal fetal
surveillance are to prevent and
reduce fetal and neonatal
morbidity and mortality
Overview

4.  1970s NST
 1980s the nipple-stimulation contraction
stress test (NS-CST)
 In 1980, Dr. Frank Manning and his
colleagues developed the biophysical profile
(BPP)
 1983, Dr. Anthony Vintzileos and his
colleagues added placental grading to
Manning’s five variables
history of the biophysical profile

5. FHR acceleration
FBM
FM
Fetal tone
Suckling
Eye movement
Swallowing
Fetal biophysical activity

6. NST
4 US parameter
( AFV, FBM, tone , FM)
Parameter of BPP
(manning 1980)

7. Behavior Gestational Age
(Weeks)
tone, slight movement 7
general movement 8
hiccups 9
limb movements 10
hand to face contact 10
respiratory movements 11
sucking/swallowing 13
BIOPHYSICAL FETAL DEVELOPMENT

8.  The BPP is based on the Gradual
Hypoxia Concept.
 Depletion of fetal oxygen (O2) affects
brain centers in a specific order
 Biophysical activities that develop first
are the last to disappear
BIOPHYSICAL FETAL DEVELOPMENT

9. BRAIN CENTER HYPOXIA AFFECTS
MEDULLA OBLONGATA ACCELERATIONS
RESPIRATORY CENTER BREATHING
MOVEMENTS
CEREBRAL CORTEX BODY MOVEMENTS
SUBCORTICAL AREA FETAL TONE
BIOPHYSICAL FETAL DEVELOPMENT

10. Acute
variables
Chronic
variables

12. ULTRASOUND EQUIPMENT

13. BIOPHYSICAL TEST INDICATIONS
 APLS
 Hyperthyroidism
 Hemoglobinopathies
 Cyanotic heart disease
 SLE
 Chronic renal dz
 DM 1 and 2
 Hypertensive disorders
 Decreased fetal movement
 Oligo/polyhydramnios
 IUGR
 Postterm pregnancy
 Isoimmunization
Moderate to severe
 Previous fetal demise
Unexplained or recurrent risk
 Multiple gestation with growth
discordancy
ACOG Educ Bull Oct 1999

14. Not enough evidence to support use
of biophysical profile (BPP) for the
assessment of fetal well-being in
high-risk pregnancies.

15. The ultrasound scan is
completed within a maximum of
30 minutes.
The average length of time for a
BPP is 10 minutes
Duration of the Test

16.  two hours after a meal
 remain sedentary at least one hour prior to
the exam
 not smoke for at least 2 hours prior to the
exam
 encouraged to arrive for testing well
hydrated
 Blood pressure (BP) may be assessed at the
initiation of the test, and every 10 minutes
during the testing period
Preparation Prior to the
Ultrasound Examination

17.  The NST is usually done prior to the
ultrasound examination.
 After the NST and prior to the
ultrasound, women will be asked to
drink enough fluid to fill their bladder.
As in all procedures, privacy should be
maintained and attention to maternal
comfort should be provided.
Preparation Prior to the
Ultrasound Examination

18. TEST SCORE CRITERIA

19.  Fetal breathing can be observed by watching
the fetal diaphragm or chest wall for
characteristic breathing motion. The fetus
must breathe continuously for 30 sec. during
the 30-minute observation period to receive
a normal score.

21.  Fetal movement of the limbs or body must occur
at least 3 times to be considered adequate.
 Normal fetal tone is demonstrated by one active
extension and flexion of the limbs or trunk.
 Opening and closing of the fetal hand also
qualifies for a normal tone score.
 Slow extension of the extremity or trunk with
incomplete return to flexion is not considered
normal.

23.  The fourth part of the BPP is measurement of
the amniotic fluid volume. Originally the
normal fluid volume was described as the
presence of at least one pocket of amniotic
fluid measuring 1 centimeter in vertical
dimension. Manning and colleagues later
modified this definition to 2 centimeters
measured vertically.

25. The 5th component of the
BPP is a non stress test,
which receives a score of
two points when reactive
and zero when
nonreactive.

26. Non-stress test physiology
 Afferent signals:
Baroreceptors: aorta, atrium, carotids
Proprioceptors: joints
Pain fibers: skin
 When stimulated, send afferent impulses to
brain to increase FHR
 Efferent signals increase FHR
 If movement and accelerations observed,
reasonable to conclude the afferent and
efferent limbs intact and cardioregulatory
neurons adequately oxygenated

28. Cont OB/GYN 2005;50:38-48

29. NST: How to do it
 Patient in lateral tilt position
 Tracing observed for 40 minutes
 Accelerations peak (but do not necessarily
remain) at least 15 BPM above baseline
 Last for 15 seconds
 Reactive: 2 or more accelerations within 20 m
period
 Nonreactive: one that lacks sufficient
accelerations over 40 minute period
 No contraindications

30. The most powerful components:
•AFI: indicator of long term uteroplacental function
•NST: short term indicator of fetal acid-base status.
assessment of fetal well-being using these two
tools alone may well be as effective as formal BPP
Modifications 1. BPP Manning (1990)
NST
AFV
results are just as predictive.

31. interpretation.,management
,outcome
 No RCT on which to base recommendation
timingBest test
frequency factors
GA effect

32. interpretation.,management
,outcome
 10/10 or 8/10 (including 2 points of AF)
Risk of developing fetal
asphyxia within one week
1/1000

33. interpretation.,management
,outcome
 6 or 8/10 (0 points of AF)
Risk of developing fetal
asphyxia within one week
89/1000

34. interpretation.,management
,outcome
 6/10 (including 2 points of AF)
Equivocal,,repeat within 24
hrs to see if one of acute
variables return to normal
or deliver if at or near term

35. interpretation.,management
,outcome
0 or 4/10
Risk of developing fetal
asphyxia within one week
91 to 600/1000
Delivery indicated

36. interpretation.,management
,outcome
 Predictive value of 4 US monitored variables
equivalent to full BPP (when the 4 variables
are normal)
 Among 12,620 women tested weekly using
the BPP, Manning and co-workers reported a
false-negative rate of 0.6 per 1000. The false-
positive rate of the BPP varies with the score
of the last test prior to delivery. Manning and
co-workers reported a false-positive rate of
zero among 11 patients in whom the last BPP
score before delivery was zero, compared to a
false-positive rate greater than 40% among 182
patients with a last BPP score of 6.

37. 1.In high-risk:
observational studies: effective
{good negative predictive value (99.9%) i.e.
fetal death is rare in women with a normal
FBP
rarely abnormal when Doppler findings
were normal}.
Advantages:

38. 1. Difficult and time-consuming
2. False-positive rate: 70%: increased rates
of unnecessary intervention.
3. Systematic review of five RCTs: failed to
demonstrate any significant benefit of BPP
on pregnancy outcome when compared to
NST
Disadvantages:

39. 4. In low risk: cannot be recommended for
routine monitoring
5. In high Risk: positive predictive value of
35% (observational study) No enough
evidence from RCTs
(Cochrane Systematic Review, 2012).:
cannot be recommended for routine
monitoring for primary surveillance in SGA
Disadvantages:

40. Factor affecting test results
Antenatal
corticosteroids,drugs
Subclinical infection
Preterm labor
fasting
Anemia >>hypotension

41. •You see what
you know

42. • The acute variables are subjected to fetal sleep wake
cycle so Continuous observation for at least 30 min
before defined to be absent
• BPP is non invasive , easily applied , accurate mean
for predicting the presence of fetal acidemia .
• Use your US machine …gain experience in
observing what you don’t see before