Motor activity of the fetus 2 points. Biophysical profile of the fetus: what is it and how to study it? Reasons for referral to a biophysical profile study

The fetal biophysical profile is used in some clinics as the primary antenatal test, while in others it is used only when the contraction stress test is positive or inconclusive. For example, the biophysical profile of the fetus is determined in the case of premature rupture of amniotic fluid. With the development of chorioamnionitis, complicating premature rupture of the membranes, the biophysical profile of the fetus is rarely satisfactory. In addition, with chorioamnionitis, the reactivity of the stress-free test disappears.

Biophysical profile of the fetus - a comprehensive assessment of the data of a stress-free test and ultrasound in real time that allows to judge the state of the fetus. The biophysical profile of the fetus includes five parameters, evaluated on a two-point system. A score of 6 or more points is considered satisfactory.

1 . Respiratory movements. The fetus makes respiratory movements episodically: there are several movements in a row, followed by a break. Normally, at least one episode of respiratory movements lasting 30 seconds for 30 minutes is recorded.

2 . movements fetus. The fetus must make at least three pronounced movements within 30 minutes (simultaneous movements of the limbs and torso are considered one movement).

3 . Tone fetus- at least one episode of movement of the limbs from a flexion to an extended position and a rapid return to its original state (within 30 minutes).

4 . Reactivity fetus(non-stress test) - the presence of two or more periods of heart rate acceleration with an amplitude of at least 15/min and a duration of at least 15 s, associated with fetal movement, during a 10-20-minute observation.

5 . Grade quantities amniotic waters. With a sufficient amount of amniotic fluid, a column of amniotic fluid (a section of amniotic fluid free from parts of the fetus and umbilical cord) of at least 2 cm in two mutually perpendicular sections in most of the uterine cavity should be visualized.

Rh-isoimmunization

The body synthesizes antibodies in response to erythrocyte antigens foreign to it. Approximately 97% of cases of hemolytic disease of the fetus and newborn are caused by isoimmunization of the pregnant woman with Rh and AB0 system Ag. Much less often, hemolytic disease of the fetus and newborn occurs due to incompatibility with other erythrocyte antigens (for example, Kell, Duffy, Kidd). Rh-isoimmunization is a humoral immune response to fetal erythrocyte antigens of the Rh group, including Cc, Dd and Ee (encoded by Rh alleles). The formed AT, penetrating the placenta, cause hemolysis of erythrocytes (opsonization of fetal erythrocytes by AT of a woman and phagocytosis of erythrocytes) and anemia, leading to the development of fetal erythroblastosis. All Rh-Ag located on the erythrocyte membrane stimulate the synthesis of IgG class antibodies in the body of a pregnant woman.

 Frequency. 1.5% of all pregnancies are complicated by fetal erythrocyte antigen sensitization. The frequency of Rh isoimmunization has decreased significantly due to the use of Rh 0 -(anti-D)-Ig.

 Epidemiology. There is a dependence of the distribution of Rh-Ag on race. So, almost all American Indians and Asians (99%) have Rh-positive blood.

With the primary penetration of foreign Ag, the body synthesizes IgM (19s-Ig). Sensitization by erythrocyte antigens can occur during childbirth (the entry of umbilical cord blood into the mother's bloodstream) or during gestation (a small amount of fetal blood through the placenta is considered normal). With subsequent exposure to antigen, IgG (7s-Ig) is synthesized as a result of a secondary immune response. Other Ig (IgE, IgD, IgA) are also synthesized in response to foreign Ag, but only IgG, due to its small size, is able to cross the placenta to the fetus.

AB0-incompatibility softens the course of pregnancy with Rh-conflict. Rh-conflict often occurs if the pregnant woman and the fetus have the same or compatible blood groups in the AB0 system. With incompatibility in the AB0 system, fetal erythrocytes, entering the body of a pregnant woman, are quickly destroyed, so anti-Rh-ATs do not have time to be synthesized.

Ultrasound examination (sonography, scanning) is the only highly informative, safe non-invasive method that allows dynamic monitoring of the fetus from the earliest stages of its development.

Dopplerography

In recent years, Dopplerography, along with cardiotocography (CTG), has become one of the leading research methods in obstetrics, as it allows you to assess the functional state of the fetus.

CARDIOTOCOGRAPHY The purpose of cardiomonitoring observation is the timely diagnosis of impaired functional state of the fetus. This allows you to choose an adequate tactics of therapeutic measures, as well as the optimal time and method of delivery.

DETERMINATION OF THE BIOPHYSICAL PROFILE OF THE FETUS

Currently, the so-called biophysical profile of the fetus is used to assess the intrauterine state of the fetus. Determination of the biophysical profile of the fetus to obtain objective information is possible already from the beginning of the third trimester of pregnancy.

The concept of "biophysical profile of the fetus" includes data from a non-stress test (with CTG) and indicators determined by ultrasound scanning: fetal respiratory movements, motor activity, fetal tone, volume of OB, degree of placental maturity. Each parameter is evaluated in points from 0 (pathology) to 2 (normal). The scores are summed up and an indicator of the condition of the fetus is obtained (Table 11-6). The sum of points 8-12 indicates the normal condition of the fetus. An assessment of the biophysical profile of the fetus of 6–7 points indicates a dubious state of the fetus. A score of 4–5 or less is an indicator of severe fetal hypoxia and a high risk of perinatal complications.

High sensitivity and specificity of the biophysical profile of the fetus are explained by a combination of markers of acute (non-stress test, respiratory movements, motor activity and fetal tone) and chronic (volume of OB, degree of maturity of the placenta) disorders of the fetus. A reactive non-stress test, even without additional data, is an indicator of a satisfactory condition of the fetus, while in the presence of a non-reactive non-stress test, ultrasound of other biophysical parameters of the fetus is of particular importance.

2. Premature birth. Etiology. Features of the course and management of preterm labor. The effect of prematurity on the fetus and newborn.

All risk factors miscarriages are divided into 4 groups: 1) social biologist causes (age, occupation, harmful habits, living conditions); 2) obstetric-gynecological anamnesis (the nature of the menstrual cycle, outcomes of previous pregnancy and childbirth, gynecological obstruction, malformations of the uterus); 3) extragenitis zab (acute inf during taking, heart defects, GB, kidney disease, diabetes mellitus); 4) complicated by this we take (severe OPG-gestoses, Rh sensitization, polyhydramnios, multiple pregnancies, placenta previa). clinical picture. On a wedge showed preterm labors share on threatening, beginning and begun.

Threatening preterm birth is not a sign of pain in the lower abdomen or in the lower back. Sometimes there are no complaints at all. Palpation of the uterus reveals increased tone and excitability. The fetal heart rate is not affected. When moisture is investigated, changes in the cervix are not found.

With the onset of preterm labor, the pain intensifies, acquires a cramping character. Moisture examination revealed a shortened or flattened cervix. Often there is an outpouring of amniotic fluid. Premature labor that has begun is characterized by regular contractions. The opening of the cervix is ​​4 cm or more, which indicates the irreversibility of the abortion process.

Diagnostics. Diagnosis of preterm birth is not difficult. It is based on complaints we take and data from external and internal obstetrics research. We take the results of a wedge examination to confirm the data of hysterography.

Doing. The tactics of preterm labor management depends on: 1) the stage of the course (threatening, beginning, beginning); 2) gestational age; 3) mother's condition (somatic diseases, late preeclampsia); 4) the state of the fetus (fetal hypoxia, fetal malformations); 5) the state of the fetal bladder (intact, opened); 6) degree of cervical dilatation (up to 4 cm, more than 4 cm); 7) the presence and intensity of bleeding; 8) the presence or absence of infection.

Depending on the current obstetric situation, conservative or active tactics are followed.

*Conservative tactics (pregnancy prolongation) is indicated for threatening or beginning labor for up to 36 weeks, whole amniotic sac, opening of the pharynx up to 4 cm, good fetal condition, in the absence of severe obstetric and somatic pathology and signs of infection.

The complex of treatment of threatening and beginning premature birth includes: 1) bed rest; 2) a light, vitamin-rich diet; 3) medicines; 4) physiotherapy; 5) reflex and psychotherapy. Pregnant women are prescribed preparations of valerian and motherwort, tazepam, sibazon, seduxen. Antispasmodics (methacin, no-shpa, papaverine), antiprostaglandins (indomethacin), calcium antagonists (isoptin) are used.

Women with threatening and preterm labor against the background of the outflow of amniotic fluid. In the absence of infection, the good condition of the mother and fetus and the gestational age of 28-34 weeks, we can prolong the take, strictly observing all the rules of asepsis and antisepsis (sterile liners, disinfection of the external genital organs, insertion of suppositories or antibacterial tablets into the vagina). It is necessary to exercise strict control over the detection of the first signs of infection of the birth canal (thermometry, blood tests, bacterium examination of vaginal discharge). When signs of infection appear, labor induction therapy is prescribed.

* Active tactics of threats and beginnings of childbirth is carried out with severe somatic diseases, severe preeclampsia, fetal hypoxia, malformations and death of the fetus, signs of infection.

Preterm labor that has begun is carried out through the natural birth canal under constant cardiac monitoring. Premature birth requires special care. It is necessary to widely use antispasmodics, apply adequate pain relief without narcotic drugs. Regulation of labor activity in case of its violations should be carried out carefully. The weakness of labor activity is corrected by intravenous administration of prostaglandins or oxytocin under careful control of cardiotocography.

Premature birth is often complicated by a rapid or rapid course. Obligatory wire professional fetal hypoxia.

In the subsequent period, a measure is taken according to the professional blood count.

Delivery by caesarean section in preterm birth is carried out according to strict indications: placenta previa, premature detachment of a normally located placenta, eclampsia, transverse position of the fetus.

A child born prematurely has signs of immaturity, so the primary treatment and all treatment activities should be carried out in an incubator.

Evaluation of the premature newborn. We take the birth of a fetus before 28 weeks, regardless of whether the fetus showed signs of life or did not show, is considered a miscarriage. If the fetus has lived for 7 days, then it is transferred to the group of live births born during premature birth.

It is customary to distinguish 4 degrees of prematurity in children depending on body weight at birth: I degree of prematurity - 2500-2001 g; II - 2000-1501; III - 1500-1001 g; IV- 1000 g or less.

The appearance of preterm babies is peculiar: the physique is disproportionate, the lower limbs and neck are short, the umbilical ring is low, the head is relatively large. The bones of the skull are pliable, the sutures and the small (posterior) fontanel are open. Ears are soft. On the skin of the back, in the area of ​​the shoulders, on the forehead, cheeks and thighs, abundant growth of vellus hair is noted. Skin thin: fiziol an erythema is distinctly expressed. The subcutaneous fat layer is thinned or absent, remaining only in the cheek area. The nails do not reach the fingertips. The genital gap in girls gapes, since the large labia do not cover the small ones. In boys, the testicles did not descend into the scrotum.

Premature babies have functional features: they are characterized by lethargy, drowsiness, decreased muscle tone, weak cry, underdevelopment or absence of a swallowing or sucking reflex, imperfection of thermoregulation.

As for all newborns and premature babies, one minute later and again 5 and 10 minutes after birth, the status is assessed according to the Apgar scale. In addition, for diagnosing and assessing the severity of syndrome disorders in premature newborns, the Silverman-Andersen scale was proposed. Assessment using this scale is wired every 6 hours after birth for 1-2 days.

Ticket number 32.

Biophysical profile of the fetus- a complex of studies, including physical activity, respiratory movements, heart rate, fetal tone and the amount of amniotic fluid, which allows you to objectify the condition of the fetus.

Test Method:
a) a non-stress test is performed (see question non-stress test)

b) the fetus is observed using real-time ultrasound for 30 minutes in order to identify criteria (see table). It is better to conduct the study after eating.

Test interpretation:
a) normal test - the number of points 10-8 (out of 10 possible)

b) suspicious - 6-7 points, i.e. chronic asphyxia is possible and the test must be repeated within 24 hours

c) less than 6 points - a serious risk of chronic hypoxia, which requires a repetition of the non-stress test immediately and if the result is the same, then an emergency delivery is necessary

d) any number of points less than 10 with the presence of oligohydramnios - an indication for immediate delivery (if oligohydramnios is not associated with rupture of the membranes).

Criteria for evaluating the biophysical profile

Benefits of the test:

a) can be performed on an outpatient basis

b) low false positive rate (compared to non-stress test)

c) no contraindications

d) can be used at the beginning of the third trimester of pregnancy

Disadvantages of the test:

a) requires the skill of an ultrasound specialist

b) requires more time (45-90 minutes).

Electrocardiography and fetal phonography.

Electrocardiography: direct and indirect.

a) Direct electrocardiography produced directly from the head of the fetus during childbirth with the opening of the cervix by 3 cm or more. An atrial P wave, a ventricular QRS complex, a T wave are recorded. Rarely performed.

b) Indirect electrocardiography carried out when electrodes are applied to the anterior abdominal wall of a pregnant woman (the neutral electrode is located on the thigh). This method is used mainly in the antenatal period. Normally, the ventricular QRS complex is clearly visible on the ECG, sometimes the P wave. Maternal complexes are easy to differentiate with simultaneous recording of the mother's ECG. The fetal ECG can be recorded from the 11th - 12th week of pregnancy, but in 100% of cases it can be recorded only by the end of the third trimester. As a rule, indirect electrocardiography is used after 32 weeks of pregnancy.

Phonocardiogram (PCG) the fetus is recorded when the microphone is applied to the point of best listening with a stethoscope of its heart sounds. It is usually represented by two groups of oscillations, which reflect the I and II heart sounds. Sometimes III and IV tones are registered. Fluctuations in the duration and amplitude of heart sounds are very variable in the III trimester of pregnancy and average: I tone - 0.09 s (from 0.06 to 0.13 s), II tone - 0.07 s (from 0.05 to 0. .09 s).

With simultaneous registration of ECG and FCG of the fetus, it is possible to calculate the duration of the phases of the cardiac cycle: the phase of asynchronous contraction, mechanical systole, general systole, diastole. The phase of asynchronous contraction is detected between the beginning of the Q wave and I tone, its duration is 0.02-0.05 s. Mechanical systole is the distance between the beginning of I and II tone and lasts from 0.15 to 0.22 s. The general systole includes a mechanical systole and an asynchronous contraction phase; it is 0.17-0.26 s. Diastole, calculated as the distance between the beginning of II and I tone, is 0.15-0.25 s. It is also important to calculate the ratio of the duration of the total systole to the duration of the diastole, which at the end of an uncomplicated pregnancy averages 1.23.

Cardiotocography.

Cardiotocography (CTG) of the fetus - the most accessible, reliable and accurate method for assessing the condition of the fetus during the last trimester of pregnancy. The cardiotocograph is designed in such a way that it simultaneously registers fetal heart rate, uterine contractions and fetal movement. Currently, screening controls for the condition of the fetus will be carried out both on an outpatient basis and in a hospital. In risk groups for perinatal losses, screening control is carried out in dynamics. Usually, fetal heart rate registration is used from 30 ice. pregnancy on a tape moving at a speed of 10 to 30 mm / min, for at least 30 minutes.

To characterize the condition of the fetus using CTG, the following indicators are used: basal heart rate, basal rate variability, frequency and amplitude of oscillations, amplitude and duration of accelerations and decelerations, fetal heart rate in response to contractions, fetal movements and functional tests.

a) Basal rhythm (BR) - long-term change in heart rate. Its decrease below 110 beats / min is classified as bradycardia, and an increase of more than 160 beats / min is classified as tachycardia. Therefore, a long-term heart rate in the range of 110-160 beats / min is regarded as a normal area. Tachycardia according to severity is distinguished: mild (160-170 beats / min) and severe (more than 170 beats / min). Bradycardia is also divided into mild (110-100 bpm) and severe (less than 100 bpm) severity. If bradycardia manifests itself in a time interval of no more than 3 minutes, and then it returns to the original BR, then it is called deceleration.

b) Variability characterized by an instantaneous frequency or short-term fluctuations in heart rate, corresponding to the time interval between two consecutive heartbeats. To the naked eye, these slight changes in short-term variability are not noticeable with other standard information. They are evaluated using computer systems. In practice, when assessing the condition of the fetus, it is always long-term or slow variability that is referred to as oscillation. Oscillations are periodic deviations from the average level of BR, which are based on instantaneous contractions of the heart muscle from beat to beat. This long-term variability is characterized by the amplitude and frequency of the oscillations.

c) amplitude, or the width of the record, counted between the maximum and minimum deviations in heart rate within 1 min. It is expressed in beats per minute. Depending on the magnitude of the amplitude, the following types of oscillations are distinguished:

"mute" or monotonous type (deviations from the basal level are 5 or less beats per minute);

"slightly undulating" - 5-9 beats / min

"undulating" (uneven, intermittent) type, when short-term periods with a decrease in the amplitude of slow oscillations are repeatedly interrupted by normal CTG and flattening periods exceed 10 minutes (deviations from the basal level within 10-25 beats / min);

"saltatory" (jumping) type, often combined with a high frequency of oscillations (deviations from the basal level of more than 25 beats / min).

d) Oscillation frequency determine the number of intersections of the line drawn through the middle of the oscillation in 1 minute. The following types of BR variability are distinguished by frequency:

Low (less than 3 oscillations per minute),

Moderate (from 3 to 6 oscillations per minute),

High (over 6 oscillations per minute). Tachycardia is characterized by an increase in heart rate for 10 minutes or more. If the heart rate increases in a time interval of up to 10 minutes, it is called acceleration. With accelerations, there is a short-term increase in heart rate by at least 15 beats / min for a period of time of at least 15 s.

Accelerations are divided into sporadic and periodic. sporadic accelerations arise in connection with the movements of the fetus or under the influence of an exogenous stimulus. Periodic accelerations occur during at least three consecutive contractions. The occurrence of acceleration before or after variable decelerations is regarded as primary and compensatory gachycardia.

Decelerations mean passing decelerations of the heart rate below the level of the average basal rate with an amplitude of at least 15 beats / min and for a time of 10 s or more.

There are 4 types of decelerations:

ü peaked- occurs sporadically or periodically, the fall and recovery of cardiac activity occurs abruptly, its duration is 20-30 s, the amplitude is 30 beats / min or more;

ü early deceleration- has a gradual beginning and end, the decrease in heart rate coincides in time with the peak of the contraction, its amplitude is proportional to the strength of the contraction, the total duration is up to 50 s;

ü late deceleration characterized by a delay in the decrease in heart rate relative to the onset of contractions, the onset is gradual, the apex is smooth, the recovery period for BR is more gentle, the total duration is more than 60 s;

ü variable deceleration indicates variability in the configuration of the wave in a different time relationship with the onset of the contraction, its shape, duration, start and recovery time may not be repeated, its amplitude ranges from 30 to 90 beats / min, the total duration is 80 s or more.

To assess the condition of the fetus according to CTG, a scoring system is used to interpret the nature of cardiac activity. On a 10-point scale, fetal cardiac activity is assessed according to the following parameters: basal rate, oscillation amplitude, oscillation frequency, acceleration, deceleration. Each feature is scored from 0 to 2 points. A score of "0" points reflects the pronounced signs of fetal suffering, 1 point - initial signs of fetal suffering, 2 points - normal parameters.

The maturation of the nervous system leads to the formation of a clear change in the periods of sleep and wakefulness in the fetus, which become distinguishable by the 20th week of pregnancy. After this period, the gynecologist may send the woman to study the biophysical profile of the fetus. In what cases is this test carried out and how to decipher it?

What is the biophysical profile of a fetus?

The biophysical profile of the fetus (BPP) is a summary assessment of the CTG study and ultrasound monitoring of the prenatal state of the child.

Ultrasound examination is carried out in real time. During the ultrasound, the amount of amniotic fluid and various types of movements of the baby are assessed.

The CTG method registers the variability of the fetal heart rate. Decoding from a cardiologist.

Indications for research

Determination of the biophysical profile of the fetus is carried out in the third trimester of pregnancy. It is prescribed to women with post-term pregnancy, as well as in the later stages, if there are the following indications:

• intrauterine growth retardation according to ultrasound data;
• diabetes mellitus, gestational diabetes, arterial hypertension and other chronic diseases that affect the course of pregnancy;
• oligohydramnios or polyhydramnios;
• reduced activity of the child;
• delayed pregnancy;
• the presence of a history of miscarriages in the later stages of unclear etiology.

Determination of the biophysical profile of the fetus

By week 28, the system of reactions to external influences is fully formed in the fetus. From this time on, the biophysical profile, also called the fetal well-being test, becomes informative.

Determination of BPP takes at least 40 minutes. During this time, the pregnant woman undergoes cardiotocography and ultrasound. To stimulate the child a little, you need to eat before the procedure.

PPP requires the results of a non-stress test. The norm is the acceleration of the number of heart beats after the child's own movements. If there are signs of depression of cardiac activity, then the heart rate will remain unchanged or, on the contrary, will slow down. To conduct CTG, a sensor is used that determines the tone of the uterus. It is placed on the abdomen above the navel, shifted to the right corner of the uterus.

The second sensor is placed in the projection of the back of the fetus, it registers the heart rate. A woman is given a special button in her hand, which she presses when a movement occurs. The duration of the recording is 20 minutes.

The fetal heart rate is extremely important:

• The work of the kidneys depends on the heart rate. A decrease in urine output leads to a decrease in the amount of amniotic fluid.
• The heart rate may indicate oxygen starvation, which, under various pathological conditions, leads to acidosis, which depresses the nervous system and cardiac activity.

Ultrasound is performed continuously for 30 minutes. If all indicators are recorded as normal, then the time is reduced. During an ultrasound, the doctor evaluates:

• Respiratory movements of the chest - they are fickle, appear and disappear spontaneously. The episode is the moment from the beginning to the end of the respiratory movements. Normally, it is at least 60 seconds in half an hour.
• Flexion or extensor movements of the trunk or limbs - they assess the tone. If the neck, arms, or legs are in an extended position, this is considered abnormal and may indicate serious problems, including antenatal death.
• Motor activity, that is, any movement, displacement, rotation of the torso, arms or legs. Their total number during the study is calculated.
• The volume of amniotic fluid - it reflects the metabolic state of the fetus.
• The degree of maturity of the placenta - indicates the possible causes of hypoxia.

BPP decoding

The severity of each indicator is estimated in points from 0 to 2. The norm of the biophysical profile of the fetus indicates no risk.

Non-stress test:

• 2 points if there were 5 episodes of heart rate acceleration in response to movement lasting from 15 seconds. with a force of at least 15 strokes;
• 1 point is given for 2-4 such episodes;
• episode - 0 points.

Breathing movements:

• receive the maximum score if there were 1 or more episodes, lasting from 60 seconds;
• periods of 30-60 sec. receive 1 point;
• absence or breathing for less than 30 seconds. - 0 points.

Motor movements:

• 3 or more motor movements are 2 points;
• for 1-2 movements put 1 point;
• 0 for no movement.

Flexion or extension movements:

• Muscle tone is considered normal, in which at least one episode of limb and back flexion-extension is recorded, 2 points are given for it.
• The score is given in the presence of one of the listed episodes.
• Persistent extension, open palms is 0 points.

amniotic fluid:

• should be in all pockets, depth from 2 cm;
• pockets 1-2 cm are valued at 1 point;
• less than 1 cm - 0 points.

The degree of maturity of the placenta:

• 2 points are set for 0, 1, 2 degrees of placental maturity;
• if its visualization is difficult, put 1 point;
• the aging placenta of the 4th degree is estimated at 0 points.

The scores obtained are summarized:

• The maximum possible amount is 12 points. The biophysical profile of the fetus 8 and 9 points is also considered the norm.
• A score of 6-7 is considered doubtful. It requires additional observation and examination. A woman may be offered hospitalization in the pregnancy pathology department at the maternity hospital.
• 5 or less points indicate a deep suffering of the fetus, which can lead to his death.

In the latter case, after the ultrasound room, the woman is urgently sent for hospitalization by her obstetrician-gynecologist. In a difficult situation, early delivery by caesarean section is performed to save the life of the child.

Yulia Shevchenko, obstetrician-gynecologist, specially for the site

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