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Biophysical
profile
Dr. Waleed Tawfik
 overview of the biophysical profile
 Fetal physiology related to biophysical testing
 Ultrasound equipment,
 testing ...
The goals of antepartal fetal
surveillance are to prevent and
reduce fetal and neonatal
morbidity and mortality
Overview
 1970s NST
 1980s the nipple-stimulation contraction
stress test (NS-CST)
 In 1980, Dr. Frank Manning and his
colleague...
FHR acceleration
FBM
FM
Fetal tone
Suckling
Eye movement
Swallowing
Fetal biophysical activity
NST
4 US parameter
( AFV, FBM, tone , FM)
Parameter of BPP
(manning 1980)
Behavior Gestational Age
(Weeks)
tone, slight movement 7
general movement 8
hiccups 9
limb movements 10
hand to face conta...
 The BPP is based on the Gradual
Hypoxia Concept.
 Depletion of fetal oxygen (O2) affects
brain centers in a specific or...
BRAIN CENTER HYPOXIA AFFECTS
MEDULLA OBLONGATA ACCELERATIONS
RESPIRATORY CENTER BREATHING
MOVEMENTS
CEREBRAL CORTEX ...
Acute
variables
Chronic
variables
ULTRASOUND EQUIPMENT
BIOPHYSICAL TEST INDICATIONS
 APLS
 Hyperthyroidism
 Hemoglobinopathies
 Cyanotic heart disease
 SLE
 Chronic renal ...
Not enough evidence to support use
of biophysical profile (BPP) for the
assessment of fetal well-being in
high-risk pregna...
The ultrasound scan is
completed within a maximum of
30 minutes.
The average length of time for a
BPP is 10 minutes
Dura...
 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 NST is usually done prior to the
ultrasound examination.
 After the NST and prior to the
ultrasound, women will be ...
TEST SCORE CRITERIA
 Fetal breathing can be observed by watching
the fetal diaphragm or chest wall for
characteristic breathing motion. The f...
 Fetal movement of the limbs or body must occur
at least 3 times to be considered adequate.
 Normal fetal tone is demons...
 The fourth part of the BPP is measurement of
the amniotic fluid volume. Originally the
normal fluid volume was described...
The 5th component of the
BPP is a non stress test,
which receives a score of
two points when reactive
and zero when
nonre...
Non-stress test physiology
 Afferent signals:
Baroreceptors: aorta, atrium, carotids
Proprioceptors: joints
Pain fibers: ...
Cont OB/GYN 2005;50:38-48
NST: How to do it
 Patient in lateral tilt position
 Tracing observed for 40 minutes
 Accelerations peak (but do not ne...
The most powerful components:
•AFI: indicator of long term uteroplacental function
•NST: short term indicator of fetal aci...
interpretation.,management
,outcome
 No RCT on which to base recommendation
timingBest test
frequency factors
GA effect
interpretation.,management
,outcome
 10/10 or 8/10 (including 2 points of AF)
Risk of developing fetal
asphyxia within on...
interpretation.,management
,outcome
 6 or 8/10 (0 points of AF)
Risk of developing fetal
asphyxia within one week
89/1000
interpretation.,management
,outcome
 6/10 (including 2 points of AF)
Equivocal,,repeat within 24
hrs to see if one of acu...
interpretation.,management
,outcome
0 or 4/10
Risk of developing fetal
asphyxia within one week
91 to 600/1000
Delivery i...
interpretation.,management
,outcome
 Predictive value of 4 US monitored variables
equivalent to full BPP (when the 4 vari...
1.In high-risk:
observational studies: effective
{good negative predictive value (99.9%) i.e.
fetal death is rare in wom...
1. Difficult and time-consuming
2. False-positive rate: 70%: increased rates
of unnecessary intervention.
3. Systematic re...
4. In low risk: cannot be recommended for
routine monitoring
5. In high Risk: positive predictive value of
35% (observatio...
Factor affecting test results
Antenatal
corticosteroids,drugs
Subclinical infection
Preterm labor
fasting
Anemia >>hypoten...
•You see what
you know
• The acute variables are subjected to fetal sleep wake
cycle so Continuous observation for at least 30 min
before defined...
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Presentationbiophysical profile1

  1. 1. Biophysical profile Dr. Waleed Tawfik
  2. 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. 3. The goals of antepartal fetal surveillance are to prevent and reduce fetal and neonatal morbidity and mortality Overview
  4. 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. 5. FHR acceleration FBM FM Fetal tone Suckling Eye movement Swallowing Fetal biophysical activity
  6. 6. NST 4 US parameter ( AFV, FBM, tone , FM) Parameter of BPP (manning 1980)
  7. 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. 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. 9. BRAIN CENTER HYPOXIA AFFECTS MEDULLA OBLONGATA ACCELERATIONS RESPIRATORY CENTER BREATHING MOVEMENTS CEREBRAL CORTEX BODY MOVEMENTS SUBCORTICAL AREA FETAL TONE BIOPHYSICAL FETAL DEVELOPMENT
  10. 10. Acute variables Chronic variables
  11. 11. ULTRASOUND EQUIPMENT
  12. 12. 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
  13. 13. Not enough evidence to support use of biophysical profile (BPP) for the assessment of fetal well-being in high-risk pregnancies.
  14. 14. 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
  15. 15.  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
  16. 16.  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
  17. 17. TEST SCORE CRITERIA
  18. 18.  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.
  19. 19.  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.
  20. 20.  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.
  21. 21. The 5th component of the BPP is a non stress test, which receives a score of two points when reactive and zero when nonreactive.
  22. 22. 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
  23. 23. Cont OB/GYN 2005;50:38-48
  24. 24. 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
  25. 25. 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.
  26. 26. interpretation.,management ,outcome  No RCT on which to base recommendation timingBest test frequency factors GA effect
  27. 27. interpretation.,management ,outcome  10/10 or 8/10 (including 2 points of AF) Risk of developing fetal asphyxia within one week 1/1000
  28. 28. interpretation.,management ,outcome  6 or 8/10 (0 points of AF) Risk of developing fetal asphyxia within one week 89/1000
  29. 29. 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
  30. 30. interpretation.,management ,outcome 0 or 4/10 Risk of developing fetal asphyxia within one week 91 to 600/1000 Delivery indicated
  31. 31. 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.
  32. 32. 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:
  33. 33. 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:
  34. 34. 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:
  35. 35. Factor affecting test results Antenatal corticosteroids,drugs Subclinical infection Preterm labor fasting Anemia >>hypotension
  36. 36. •You see what you know
  37. 37. • 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

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