You're in your third trimester. Your baby may be a few days late, or perhaps there are some risk factors associated with your pregnancy. And so your doctor recommends a Biophysical Profile. The test is painless and comes with very little risk to you or your baby — and it may be an important way to determine whether your baby is as responsive and alert as it should be. Show
Why Biophysical Profile Testing Is DoneThis test can be done in the later stages of pregnancy. It is more frequently used in cases where the mother is going past her assigned due date to ensure fetal well-being. In some cases it is done as a precaution after problems in a previous pregnancy or because of high-risk factors such as previous pregnancy loss in the second half of pregnancy, high blood pressure, diabetes, intrauterine growth retardation (IUGR), Your doctor may also suggest a BPP if you have lupus, kidney disease, or hyperthyroidism. How the Test Is DoneThis test is usually done in your practitioner's office. One of the major parts of the BPP is a detailed ultrasound. During the ultrasound, the technician is looking for movements of your baby's arms and legs (muscle tone), movements of the body, breathing movements (moving chest muscles), and the measurement of amniotic fluid. The second portion of the test consists of a non-stress test. Part of the test is intended to observe your baby's movement - but a lack of movement isn't necessarily an issue. Because your baby is just as likely to be asleep as awake, the person doing the test may actually use a buzzer to wake the baby up. When the Test Is DoneThis test is most frequently done between weeks 38 and 42, however, it can be used as early as the beginning of the third trimester. How the Results Are GivenYour baby will be scored on five things during the test. A score of 0 (abnormal) or 2 (normal) will be given in each of these categories:
A score of below 6 is worrisome and action will probably be taken, which may include induction or cesarean section. Six is considered borderline. The test may be repeated as often as daily until the baby is born, though most often it is a one-time event or a weekly event depending on the reason for the biophysical profile. Risks InvolvedThe BPP is a noninvasive test that poses few risks to mother or baby. The two most common concerns are a misinterpretation of the data and exposure to ultrasound. Misinterpretation of data may lead to unnecessary induction of labor or even to an unnecessary C-section. Prenatal exposure to ultrasound not been definitively linked to fetal damage, but because the scan does heat tissue there is a potential risk to be considered. Where to Go From HereIf the baby is still not as responsive as they would like you may either go to a stress test or even induction or cesarean section.  By
Robin Elise Weiss, PhD, MPH Thanks for your feedback! David H. Chestnut MD, in Chestnut's Obstetric Anesthesia, 2020 An NST alone may not be sufficient to confirm fetal well-being. In such cases, a biophysical profile (BPP)
may be performed. The BPP combines an NST with an ultrasonographic scoring system performed over a 30-minute period. Initially described for testing of the postterm fetus, the BPP has since been validated for use in both term and preterm fetuses, but not during active labor.75,76 The five variables described in the original BPP were (1) gross fetal body movements, (2) fetal tone (i.e., flexion and extension of limbs), (3) amniotic fluid volume, (4) fetal breathing
movements, and (5) the NST (Table 6.4).75 More recently, the BPP has been interpreted without the NST. The individual variables of the BPP become apparent in the normal fetus in a predictable sequence: fetal tone appears at 7.5 to 8.5 weeks’ gestation, fetal movement at 9 weeks, fetal breathing at 20 to 22 weeks, and FHR reactivity at 24 to 28 weeks. In the setting of antepartum hypoxia, these characteristics
typically disappear in the reverse order of their appearance (i.e., FHR reactivity is lost first, followed by fetal breathing, fetal movements, and finally fetal tone).76 The amniotic fluid volume, which is composed almost entirely of fetal urine in the second and third trimesters, is not influenced by acute fetal hypoxia or acute fetal central nervous system dysfunction. Rather, oligohydramnios (decreased amniotic fluid volume) in the latter half of pregnancy and in the
absence of ruptured membranes is a reflection of chronic uteroplacental insufficiency and/or increased renal artery resistance leading to diminished urine output.77 It predisposes to umbilical cord compression, thus leading to intermittent fetal hypoxemia, meconium passage, or meconium aspiration. An adverse pregnancy outcome (including a nonreassuring FHR tracing, low Apgar scores, and/or admission to the neonatal intensive care unit) is more common when oligohydramnios
is present.78,79 Weekly or twice-weekly screening of high-risk pregnancies for oligohydramnios is important because amniotic fluid can become drastically reduced within 24 to 48 hours.80 Although each of the five features of the BPP are scored equally (2 points if the variable is present or normal and 0 points if absent or abnormal, for a total of 10 points), they are not equally predictive of adverse
pregnancy outcome. For example, amniotic fluid volume is the variable that correlates most strongly with adverse pregnancy events. The management recommended on the basis of the BPP score is summarized inTable 6.5.81 A score of 8 or 10 is regarded as reassuring; a score of 6 is considered equivocal, and a score of 4 or less is abnormal. A score of 0 or 2 suggests nonreassuring fetal status (previously referred to as “fetal distress”) and should prompt
evaluation for immediate delivery.76,82 Intrauterine Growth RestrictionAhmet Alexander Baschat, Henry L. Galan, in Obstetrics: Normal and Problem Pregnancies (Seventh Edition), 2017 Biophysical ParametersThe five-component fetal BPP was developed by Manning and colleagues and has been widely used in the surveillance of growth-restricted fetuses. A graded system is applied to categorize fetal tone, movement, breathing movement, heart rate reactivity, and a maximum amniotic fluid pocket as normal (2 points) or abnormal (0 points). If used in the context of the BPP, fetal heart rate reactivity criteria that account for gestational age are used. Reactivity has been defined prior to 32 weeks' gestation as accelerations greater than 10 beats/min sustained for more than 10 seconds; between 32 to 36 weeks' gestation, accelerations greater than 15 beats/min sustained for more than 15 seconds; and after 36 weeks' gestation, accelerations greater than 20 beats/min sustained for more than 20 seconds. In anatomically normal fetuses, the presence of the dynamic variables is related to physiologic variations in maturation and behavioral state as well as acid-base status. Vintzileos and coworkers have demonstrated that four components of the BPP are affected at different levels of hypoxemia and acidemia. The earliest manifestations of abnormal fetal biophysical activity consist of the loss of heart rate reactivity along with the absence of fetal breathing. This is followed by decreased fetal tone and movement in association with more advanced acidemia, hypoxemia, and hypercapnia. Because of the relationship between AFV and vascular status, amniotic fluid assessment provides the only marker of chronic hypoxemia and is the only longitudinal monitoring component of the BPP. Growth-restricted fetuses preserve acute central responses to acid-base status despite their maturational delay and are at risk for oligohydramnios. The five-component BPP accounts best for physiologic and individual variations in behavior and therefore remains closely related to arterial pH in fetuses with IUGR without anomalies from 20 weeks onward.60 An abnormal score of 4 or less is associated with a mean pH of less than 7.20, and sensitivity in the prediction of acidemia is 100% for a score of 2 or less. A normal score and normal AFV indicate the absence of fetal acidemia at the time of testing. Longitudinal observations in growth-restricted fetuses have shown that the BPP deteriorates late and often rapidly.20 Whereas an abnormal BPP is associated with escalating risks for stillbirth and perinatal mortality, a normal score allows no anticipation of fetal deterioration and stillbirth. In summary, assessment of fetal biophysical variables provides an accurate measure of fetal status at the time of testing. In the patient with a nonreactive NST, a full five-component BPP must be performed. As a back-up test for a nonreactive FHR test, the BPP leads to lower rates of intervention, when compared with the CST, without jeopardizing perinatal outcome. In the presence of normal AFV, a normal BPP of 8 (−2 for a nonreactive NST) or 10 is reassuring of fetal well-being. Nevertheless, in the absence of knowledge about placental vascular status, the rate of progression cannot be anticipated and may require even daily testing in severe IUGR. The development of oligohydramnios is concerning and frequently requires modification of management or delivery. The knowledge of fetal Doppler status is complementary to BPP because it improves the anticipation of fetal deterioration and provides an additional means to assess fetal state.61 Read full chapter URL: https://www.sciencedirect.com/science/article/pii/B9780323321082000330 Intrauterine Growth RestrictionRobert Resnik MD, in Creasy and Resnik's Maternal-Fetal Medicine: Principles and Practice, 2019 Biophysical Profile and Amniotic Fluid VolumeThe BPP is appealing, inasmuch as it provides a multidimensional survey of fetal physiologic parameters. In particular, AFV assessment is an important aspect of the BPP because oligohydramnios is a frequent finding in an FGR pregnancy caused by placental insufficiency. This is presumably a result of diminished fetal blood volume, renal blood flow, and urinary output. Human fetal urinary production rates can be measured with considerable accuracy,132 and three separate studies have shown decreased rates in the presence of FGR.133-135 Although AFV assessment alone is not a reliable screening test for FGR, it appears to have value as an indicator of fetal outcome.15 Specifically, severe oligohydramnios is associated with a high risk of fetal compromise.136,137 It is likely that the chronic hypoxic state frequently observed in fetuses with IUGR is responsible for diverting blood flow from the kidney to other organs that are more critical during fetal life. Nicolaides and associates135 observed reduced fetal urinary flow rates in IUGR, and the degree of reduction was well correlated with the degree of fetal hypoxemia as reflected by fetal Po2 measured after cordocentesis. The most appropriate techniques for assessment of AFV as well as the arguments for and against each technique are addressed inChapter 34. It is reasonable to conclude that a clinically significant decrease in AFV is suggested by a single vertical pocket smaller than 2 cm, an amniotic fluid index less than 5 cm, or both. In a multicenter randomized controlled trial of 1052 singleton pregnancies in which the amniotic fluid index and single vertical pocket parameters for oligohydramnios were compared, the use of the amniotic fluid index increased the rate of diagnosis of oligohydramnios and labor induction without any improvement in outcome.138 It appears that the single vertical pocket is more closely related to outcome and less associated with unnecessary labor induction. There is a paucity of evidence from randomized trials to validate use of the BPP.139 However, its usefulness was suggested by several large observational reports. In a study of 19,221 high-risk pregnancies, Manning and colleagues140 observed that the fetal death rate after a normal BPP score (≥8) was 0.726 in 1000 births; only 14 fetuses died. Of the total patient population, approximately 4380 pregnancies were complicated by FGR, and only 4 of the infants with FGR died after a normal test, yielding a false-negative test rate of less than 1 in 1000. We use the BPP as an adjunct to Doppler velocimetry. For example, if the BPP is normal in the presence of absent or reversed umbilical artery end-diastolic flow in a very preterm fetus, monitoring may be continued daily in an attempt to gain a modest increase in gestational age, as the latter is the primary determinant of survival and degree of morbidity. PerinatologyVinnie DeFrancesco, in Clinical Engineering Handbook, 2004 Ultrasonic ScannersUltrasonic scanners use measure fetal age, gestational age, and fetal weight to obtain multiple ratio calculations, fetal biophysical profile, and twin gestational measurements and to generate reports. These are standard obstetric parameters that are usually incorporated into general ultrasound-imaging units (Goldberg et al., 1995). Computerized ultrasound units have specific programs and built-in ultrasound probes. Most machines allow for all fetal-growth data and ratio data to be stored on one 3.5-inch diskette for convenient data storage and retrieval and report printing. A PM program for ultrasonic scanners should follow the manufacture's suggestions. Required testing phantoms are required, to perform the recommended tests to ensure the proper operation of the ultrasonic scanner and probes. Replacement probes need not be repaired or purchased from the manufacture of the ultrasonic scanner unless they are specialized. Read full chapter URL: https://www.sciencedirect.com/science/article/pii/B9780122265709501022 Assessment of Fetal HealthRobert Resnik MD, in Creasy and Resnik's Maternal-Fetal Medicine: Principles and Practice, 2019 Biophysical ProfileThe BPP relies on the premise that multiple parameters of well-being are better predictors of outcome than any single parameter.15Fig. 34.2 shows a detailed evaluation of outcome variables performed during development.16,17 The traditional BPP study includes five variables (Table 34.1), with a total possible score of 10, but several variations have been proposed. Vintzileos and colleagues18 added placental grading, for a total possible score of 12. Several investigators proposed a modified BPP that usually includes heart rate monitoring and amniotic fluid evaluation.19,20 There are modest differences in these approaches, but all emphasize the principle of multivariable fetal assessment. Biophysical Profile Score VariablesAmniotic Fluid MeasurementThe physiologic principle connecting decreased amniotic fluid volume to fetal compromise is the understanding that fetal oliguria in an anatomically normal fetus is a consequence of redistribution of fetal blood flow away from the kidneys and is frequently a reflection of uteroplacental insufficiency.21 Many methods of assessing amniotic fluid volume have been suggested. The technique for determining the BPP requires assessment of a single adequate pocket of fluid. With the transducer vertical to the maternal abdomen, the maximum vertical depth of a clear amniotic fluid pocket is recorded. The transducer is then rotated 90 degrees in the same vertical axis, confirming that the measured pocket has true biplanar dimensions. The phrase2 × 2 pocket does not mean that the pocket is 2 cm deep and 2 cm wide; it refers to the documentation that the pocket is 2 cm deep in at least two intersecting ultrasound planes, avoiding the possibility that a sliver of amniotic fluid is misconstrued as a true three-dimensional pocket. Amniotic fluid is measured in real time, and when there is doubt about a true pocket, it is confirmed by pulsed Doppler. Continuous color imaging may lead to the false impression of oligohydramnios (Fig. 34.3).22 This method reflects the relative amount of amniotic fluid and was not meant for determining an absolute physiologic parameter.23 A deepest vertical pocket (DVP) that is less than 2 cm or more than 8 cm suggests oligohydramnios or polyhydramnios, respectively; in this setting, a detailed fetal evaluation is suggested to exclude anatomic and anomalous explanations.24 For moderately increased fluid (i.e., maximum vertical pocket depth of 8 to 12 cm), the most common explanations are idiopathic polyhydramnios, fetal macrosomia resulting from maternal diabetes, and structural abnormalities, and fetal testing is likely to reflect fetal neurologic and acid-base status accurately. For pockets deeper than 12 cm in singleton pregnancies, neurologic issues and structural defects associated with aneuploidy are more likely (especially if associated with fetal growth restriction), and the BPP may not predict the neonatal outcome.25 Through the normal range (i.e., maximum vertical pocket depth of 3 to 8 cm), the maximum vertical depth method assigns normal status accurately, although it may not correlate precisely with absolute volumes. The original criterion for the diagnosis of oligohydramnios was a maximum vertical pocket of only 1 cm. Although this finding highly correlated with IUGR, it was so uncommon as to be clinically meaningless. A meta-analysis identified four high-quality, randomized, controlled trials (RCTs) that compared the amniotic fluid index (AFI) with the single DVP with respect to preventing adverse pregnancy outcome. The limits used were an AFI less than 5 cm and a DVP less than 2 × 1 cm. The trials included 3125 women, with the primary outcome measure defined as admission to the neonatal intensive care unit. No difference was observed for the primary outcome (risk ratio [RR] = 1.04; confidence interval [CI], 0.85 to 1.26).26 When the AFI was used for fetal surveillance, however, the diagnosis of oligohydramnios was made more frequently (RR = 2.33; CI, 1.67 to 3.24); labor induction was used more frequently (RR = 2.1; CI, 1.6 to 2.76), and there was a higher rate of cesarean deliveries for lack of assurance of fetal well-being (RR = 1.45; CI, 1.07 to 1.97).26 There were no differences in Apgar scores, umbilical artery pH (<7.1), or nonreassuring FHR tracings. The study authors concluded that the DVP seemed to be superior to the AFI for fetal surveillance because it required less intervention and resulted in a similar perinatal outcome. Diabetic KetoacidosisGiancarlo Mari M.D., M.B.A., F.A.C.O.G., F.A.I.U.M., F.A.G.O.S., in Safety Training for Obstetric Emergencies, 2019 Fetal Monitoring• Fetal heart rate monitoring during the acute episode of diabetic ketoacidosis often reveals minimal or absent variability, absent accelerations, and repetitive variable and late decelerations (Fig. 22.3). The fetal biophysical profile can also be abnormal, and Doppler studies may show signs of blood flow redistribution (i.e., increased umbilical artery pulsatility index and reduced middle cerebral artery pulsatility index) •It may take 4–8 hours for the fetal heart rate tracing to become normal •Mortality and morbidity may be increased by cesarean delivery. DKA alone is not an indication for delivery. It is critical to stabilize the maternal condition before consideration, as this will often improve fetal status. If the condition does not improve despite aggressive DKA management, delivery may be indicated Read full chapter URL: https://www.sciencedirect.com/science/article/pii/B9780323696722000229 BREATHING | Fetal BreathingR. Harding, ... C.A. Albuquerque, in Encyclopedia of Respiratory Medicine, 2006 Use of FBMs in Clinical AssessmentIn the healthy human fetus, FBMs occur at an average frequency of 60 per min and are accompanied by increased body movements and heart rate variability. FBMs are first detectable at about 10–12 weeks of gestation when they are usually irregular and sporadic. From about 28 weeks of gestation onwards, FBMs become more regular and organized into discrete episodes. Using color Doppler and spectral ultrasonography analyses, the breath-to-breath interval and the inspiratory phase of the respiratory cycle have been shown to increase from 22 to 35 weeks gestation, but then decrease towards term. FBMs are used as one component of the ‘fetal biophysical profile’ which is widely used to assess fetal health; the occurrence of FBMs is observed, together with assessments of fetal heart rate, amniotic fluid volume, fetal body movements, and fetal body dimensions. If FBMs are not detected, the fetus may be hypoxic, may have a neural disorder affecting the brainstem and phrenic motor nerves, or it may have an abnormality of skeletal muscle function. However, it must be recognized that the inhibition of FBMs by chronic fetal hypoxia may be only transient, as has been shown in sheep (Figure 1). FBMs have also proven to be useful for the diagnosis of intrauterine infection in patients with preterm rupture of membranes as they have a high negative predictive value for intra-amniotic infection; a depression in FBM incidence is non-specific but is suggestive of infection. Studies of patients with premature rupture of membranes have shown a decrease in FBM incidence in those patients positive for amniotic fluid infection, clinical chorioamnionitis, or neonatal sepsis. This may be related to inflammatory cytokines affecting fetal behavioral states. Read full chapter URL: https://www.sciencedirect.com/science/article/pii/B0123708796000430 Trauma and Related Surgery in PregnancyHaywood L. Brown, in Obstetrics: Normal and Problem Pregnancies (Seventh Edition), 2017 Fetal MonitoringFetal and uterine contraction monitoring is the most sensitive method for detecting abruptio placentae following trauma. In pregnant women who are beyond 23 to 24 weeks' gestation, frequent uterine contractions are nearly always present in women who develop placental abruption following trauma.44,45 Moreover, a nonreassuring fetal heart rate (FHR) pattern may reflect maternal hemorrhagic shock or hypotension.18 Uterine contraction monitoring is unquestionably more sensitive than ultrasound in detecting placental abruption, and ultrasound detects only about 40% of abruptio placentae in the setting of trauma.18,20,46 Although several authors have recommended incorporating assessment of fetal status into the standard focused abdominal sonography for trauma (FAST) exam, it should not replace fetal monitoring.14,47 The standard FAST exam is performed to evaluate for intraperitoneal hemorrhage and has replaced diagnostic peritoneal lavage in many centers because of its excellent sensitivity (80% to 83%) for detection of intraperitoneal fluid.47 A fetal biophysical profile test and middle cerebral artery Doppler studies may be performed at the time of the FAST exam for further information regarding fetal well-being, although its ability to predict fetal outcome in the setting of trauma has not been thoroughly assessed.14,47 The FHR tracing has been called the “fifth vital sign” because it may provide the earliest evidence of maternal hypovolemia or hypotension (Fig. 26-3).14 Likewise, frequent uterine contractions provide the most reliable warning sign of placental abruption or preterm labor.15,46,48 The time within which a pregnant woman with trauma should receive fetal monitoring is variable. The rationale for a prolonged period of monitoring is the concern for delayed abruption, which has been reported up to 6 days after a traumatic event.49 If uterine contractions occur less frequently than every 15 minutes over 4 hours of observation, placental abruption is unlikely to occur.15,45,46 In fact, delayed placental abruption is unlikely if contraction frequency is less than every 10 minutes with normal fetal heart activity over a 4- to 6-hour period of observation. Adverse outcomes directly related to trauma has a reported negative predictive value of 100% when monitoring was normal and the early warning symptoms of bleeding and abdominal pain were absent.50 Therefore if the fetus is at or beyond 24 weeks' gestation, the recommended minimal time for monitoring is at least 4 hours from the occurrence of the trauma. Monitoring should be continued if uterine tenderness, contractions, or irritability; abnormal fetal heart activity; or vaginal bleeding are evident. If deteriorating fetal status is apparent, delivery is indicated at a viable gestational age even if placental abruption is not clinically evident. If frequent contractions are noted (every 15 minutes or more often) even though no other signs and symptoms for abruption are present, 24 hours of monitoring is recommended because delayed abruptio placentae has been reported up to 48 hours or longer after maternal trauma.14,18,46 Read full chapter URL: https://www.sciencedirect.com/science/article/pii/B9780323321082000263 Clinical Management and Antihypertensive Treatment of Hypertensive Disorders of PregnancyChristianne de Groot, ... Anne Cathrine Staff, in Chesley's Hypertensive Disorders in Pregnancy (Fifth Edition), 2022 Assessment for PreeclampsiaInitial evaluation of preeclampsia should generally occur in a triage or hospital setting for adequate maternal and fetal assessment. •History and review of symptoms should include questions described above. •Serial blood pressures should be measured to confirm sustained elevations. •Physical examination should be performed with attention to signs of preeclampsia and associated complications; specifically, a thorough cardiopulmonary, abdominal, and neurologic examination. •Proteinuria should be assessed by urine protein-to-creatinine, or albumin-to-creatinine24 ratios or a 24-h urine collection. Urine dipstick test is acceptable if these are not available. As there is limited evidence that higher levels of proteinuria are associated with worse outcomes,25,26 proteinuria should primarily be used for the diagnosis of preeclampsia.27 Decision to deliver should not be based upon the degree of proteinuria.27,28 •Laboratory evaluation should include a complete blood count with platelets, liver transaminases, and serum creatinine to detect possible end-organ involvement. Although not diagnostic, uric acid may be useful in identifying a subgroup of hypertensive women who are at increased risk for premature delivery and small for gestational age infants.29 Peripheral blood smear, lactate dehydrogenase, haptoglobin, and/or indirect bilirubin may be ordered if there is concern for hemolysis and possible HELLP syndrome. •Fetal well-being should be assessed with ultrasound to evaluate estimated fetal weight, growth, and amniotic fluid index. Nonstress cardiotocograph testing and/or fetal biophysical profiles should also be performed. In the setting of fetal growth restriction, umbilical artery Doppler measurement is a useful tool to assess resistance within the placental and umbilical vasculature. Use of these measurements has been shown to reduce perinatal death as well as unnecessary delivery of the preterm growth-restricted fetuses.30 •Role of angiogenic factors in the clinical evaluation: Several recently published studies have assessed whether circulating levels of the angiogenic factors, such as placental growth factor (PlGF) and/or soluble fms-like tyrosine kinase-1 (sFlt-1), could improve clinical follow-up and outcome. Prior to 37 weeks, a normal angiogenic profile (low sFlt-1 and high PlGF) supports the absence of placental dysfunction, in line with the concept that an imbalance of these markers (high sFlt-1 and low PlGF) reflects placental syncytiotrophoblast stress31 (Please see Chapter 9 for detailed discussion of angiogenic factors). In a multicenter, prospective cohort study, Chappell and colleagues demonstrated that low PlGF (less than the fifth percentile) has high sensitivity (0.96; 95% CI, 0.89–0.99) and negative predictive value (0.98; 95% CI 0.93–0.995) for preeclampsia within 14 days in women with suspected preeclampsia prior to 35 weeks' gestation.32 Zeisler and colleagues identified and validated in an observational cohort that a ratio of serum sFlt-1 to PlGF of 38 or lower had a negative predictive value of 99.3% (95% CI 97.9–99.9) for no preeclampsia within a week among women with suspected preeclampsia between 24 weeks and 0 days and 36 weeks and 6 days.33 A follow-up study using a multicenter, stepped-wedge cluster randomized controlled study design compared a clinical algorithm incorporating PlGF to standard care without revealing PlGF to clinicians.34 Availability of PlGF substantially reduced time to clinical confirmation of preeclampsia (median time to diagnosis 4.1 days with concealed testing vs. 1.9 days with revealed testing, P = .027). Incidence of adverse maternal outcomes was lower where PlGF testing was implemented (odds ratio 0.32; 95% CI 0.11–0.96). There were no differences in adverse perinatal outcomes or gestational age at delivery.34 These data suggest the clinical utility in the setting of “rule-out” preeclampsia. Recent United Kingdom NICE guidelines recommend the Triage PlGF test and the Elecsys immunoassay sFlt-1/PlGF ratio, used with standard clinical assessment and subsequent clinical follow-up, to help rule-out preeclampsia in women presenting with suspected preeclampsia between 20 and 34 weeks plus 6 days of gestation (https://www.nice.org.uk/guidance/dg23/chapter/1-Recommendations).35 These angiogenic markers may be particularly useful among women with chronic renal disease to discriminate between worsening renal disease and new-onset preeclampsia (with placental dysfunction and therefore, low PlGF).36 Low PlGF and high sFlt-1 have also been shown to predict other manifestations of placental dysfunction37 including fetal growth restriction,38–40 spontaneous preterm labor,41 and stillbirth.42,43 The chapter authors expect that future studies will aid in resolving cost–benefit issues of introducing these markers into general clinical practice of women with suspected placental dysfunction including preeclampsia. The use of PlGF testing in first trimester screening is also increasingly used as part of an algorithm to identify women at high risk for early-onset preeclampsia,44 where a low PlGF early in pregnancy would be consistent with the concept of early syncytiotrophoblast stress predicting early-onset preeclampsia.31 Inpatient Versus Outpatient Management of PreeclampsiaAs noted, initial evaluation for preeclampsia is generally in a triage or hospital setting. Often, a 24-h or longer observation period is warranted to establish the severity and stability of preeclampsia. Inpatient management with ongoing close maternal and fetal surveillance is indicated for preeclampsia with severe features or for any evidence of disease progression. Selected patients with preeclampsia without severe features may be candidates for outpatient management. The existing, albeit limited, data indicate no difference in maternal or fetal outcomes with outpatient versus inpatient management in women without severe features of preeclampsia.45–47 A systematic review of three trials with a total of 504 women with various complications of pregnancy observed no major differences in clinical outcomes for mothers or infants comparing antenatal day unit versus hospital admission.47 A recent retrospective case series of 274 women in China with “mild” preeclampsia managed expectantly as outpatients had an increased risk of stillbirth (7%; 14/209) among women less than 34 weeks' gestation.48 All women in this series had received antihypertensive therapy to control blood pressures, suggesting that this may have been a study population with more severe or unstable preeclampsia. Outpatient management, after the initial hospital-based evaluation, is also cost-effective as long as there is confirmed stability and no severe features of preeclampsia.45,49,50 Candidates for outpatient management should be reliable and able to comply with self-monitoring of symptoms, fetal movement, and blood pressures as well as to report any changes in status and return to the hospital in a timely manner, if any worsening. Many obstetric facilities will provide weekly visits, weekly labs, twice weekly blood pressure evaluation with fetal testing. Primary health care visits or home monitoring may be offered between in-person visits. There should be a clear understanding that readmission is indicated for any evidence of disease progression. Current evidence does not support strict bed rest for the prevention of preeclampsia or associated complications51,52; furthermore, it may increase the risk of venous thromboembolism.52 The mainstay of preeclampsia management includes antihypertensive therapy, antenatal glucocorticoids for fetal maturation, magnesium sulfate for seizure prevention, and ultimately, delivery. Timing of delivery is based on gestational age, preeclampsia severity, and maternal/fetal well-being. These are discussed in the next sections. Read full chapter URL: https://www.sciencedirect.com/science/article/pii/B9780128184172000129 MCarl P. Weiner MD, MBA, FACOG, Clifford Mason PhD, in Drugs for Pregnant and Lactating Women (Third Edition), 2019 Morphine — (Avinza; Kadian; MS Contin; MSIR; Oramorph; Roxanol)International Brand NamesLog on to ExpertConsult.com for a list of all international brand names. Actiskenan (France); Algedol (Uruguay); Anafil - L.C. (Mexico); Anafil - S.T. (Mexico); Anamorph (Australia); Contalgin (Denmark); Continue DR (Korea); Dolcontin (Finland, Sweden); Dolcontin Depottab (Norway); Duralmor (Mexico); Duromorph (England, Ireland); Graten (Mexico); Kapanol (Australia); Kapanol LP (France); La Morph (New Zealand); Longphine SR (Korea); MCR (Israel); M.Elson (Hong Kong); M-Eslon (Canada, Chile, Ecuador, Peru); Meslon (Colombia); M.I.R. (Israel); M-Long (Germany); Morcontin Continus (India); Morficontin (Greece); Morphanton (Germany); Morphgesic SR (England, Ireland); Morphine Mixtures (Australia); Moscontin (France); M S Contin (Canada); MS Contin (Australia, Belgium, Canada, Italy, Netherlands); MS-Contin (Korea); MSI (Germany); MSIR (Canada); MS Mono (Australia); MSP (Israel); MST 10 Mundipharma (Germany); MST 30 Mundipharma (Germany); MST 60 Mundipharma (Germany); MST 100 Mundipharma (Germany); MST 200 Mundipharma (Germany); MST Continus (Argentina, Brazil, Bulgaria, Czech Republic, England, Hungary, Indonesia, Ireland, Israel, Malaysia, Mexico, New Zealand, Philippines, Poland, Puerto Rico, Spain, Taiwan); MST Continus Retard (Switzerland); Mundidol Retard (Austria); Oramorph (England, Ireland); Ra-Morph (New Zealand); Relimal (Philippines); Sevredol (New Zealand); S-Morphine (Korea); SRM-Rotard (Singapore); Statex (Canada, Singapore); Vendal (Uruguay)
Read full chapter URL: https://www.sciencedirect.com/science/article/pii/B9780323428743000124 Which assessments are included in the fetal biophysical profile BPP )? Select all that apply?The BPP combines the assessment of electronic fetal heart rate monitoring (CTG) with four biophysical features, namely (i) fetal movements, (ii) fetal tone, (iii) fetal breathing and (iv) estimation of amniotic fluid volume.
Which physiological parameters does the nurse check in the ultrasound report to assess fetal well being?Ultrasound evaluation.
During the biophysical profile, your provider is looking at 5 main areas to check your baby's health: body movements, muscle tone, breathing movements, amniotic fluid, and heartbeat. Each of these 5 areas is given a score of either 0 (abnormal) or 2 (normal).
When does the nurse refer the pregnant patient for ultrasonography to detect maternal abnormalities that could affect the fetus?Second trimester ultrasonography should be offered to all patients, between 18 and 22 weeks' gestation, for the detection of fetal structural abnormalities.
Which testing would be available for a client at 11 weeks of gestation who requests a fetal genetic assessment?Cell-free fetal DNA testing (also called noninvasive prenatal screening or testing). This screening test checks your blood for your baby's DNA. The DNA is examined for certain genetic conditions, such as Down syndrome. This test is done after 9 weeks of pregnancy.
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After reviewing the biophysical profile (bpp) reports of a pregnant patient close to term
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