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The biophysical profile: Comparison of single deepest pocket to four-quadrant technique for amniotic fluid assessment in the post-date gestation
340
SPO Abstracts
J a n u a r y 1995 Am J Obstet Gynecol
289 AMNIOTIC FLUID INDEX DURING U N C O M P L I C A T E D TWIN PREGNANCY, TF P o r t ~ , GA Dildy, JR BluncharcP, N K Koc,henour, SL Clerk. Department of Ob/Gyn, University of Utah, Salt Lake City, and UVRMC, Provo, LIT. OBJECTIVE: To study the estimated gestational age (EGA) trends of anmiotic fluid index (AFI) in uncomplicated twin pregnancies. S T U D Y D E S I G N : A reWospective observational study of AFI's performed in uncomplicated twin pregnancies between 1985 and 1993.
Twins meeting the following uritm'iawere included: I) no matecnal medical or obstetricalcomplications. 2) normal growth of both twins by serial ultrasound,and 3) subjectively normal anmiotic fluid volume by ultrasound. AFI was measured by adding the deepest vertical pocket in four qua&ants, defined by the umbih'cus and linex nigra. R E S U L T S : 333 sets of twins were considered uncomplicated; 1088 AFFs were performed between 26 and 40.5 weeks: EGA .K28
Sth 6.0
1Oth
~th
9Oth
9$th
N
6.8 18.9 24.0 28.0 15 29 7.2 8.8 16.0 24.5 25.1 13 30 8.9 9.7 16.6 19.2 20.9 19 31 9.1 10.3 15.3 21.0 23.1 35 32 9.7 10.3 15.9 21.7 22.9 64 33 8.7 10.1 15.2 20.4 21.7 89 34 10.2 11.2 15.0 21.1 22.2 187 35 9.4 11.2 15.7 20.4 22.1 214 36 9.5 10.8 15.1 21.1 22.9 200 37 9.1 9.9 15.2 22.7 23.9 145 3g 8.5 9.6 14.3 20.3 22.4 77 39 7.2 9.5 14.3 20.2 21.0 20 >40 8.0 10.4 14.8 25.9 29.6 10 C O N C L U S I O N : The EGA trends of AFI are described for uncomplicated twin pregnancies. This information may be useful in monitoring complicated and uncomplicated twin gestations.
290 THE BIOPHYSICAL PROFILE: COMPARISON OF SINGLE DEEPEST POCKET TO FOUR-QUADRANT TECHNIQUE FOR AMNIOTIC FLUID ASSESSMENT IN THE POST-DATE YS Thornton. CA Rufx, CL Rosen x and UC Jackson, Morristown Memorial Hospital, NJ and Columbia University College of Physicians and Surgeons, New York, NY BACKGROUND: Amniotic fluid volume decreases as gestation reaches term and beyond. Diminished unmiotic fluid has been shown to be the best predictor of intrapartum distress. OBJECTIVE: To compare the standard single deepest pocket technique [SDP] to the four-quadrant technique-- the amniotic fluid index [AFI] in their ability to detect decreasing amounts of amniotlc fluid as part of the fetal biophysical profile in the post-date gestation. S T U D Y D E S I G N : A prospective study of weekly biophysics] profiles was conducted on 107 women beginning in their 41st week of gestation. Low amniotic fluid was classified as: M a r g i n a l fluid having a SDP <2 cm and >1 cm or the AFI <8 cm and ~.5 cm and decreased fluid was defined as the SDP <1 cm and the AFI <5 cm. Statistical analysis was performed by Z2, McNemar test and the Fishers exact test. R E S U L T S : Of the 107 patients, low amniotic fluid was observed in 17 patients using the AFI compared to only 5 patients using the SDP (1)<0.008). Marginal amniotic fluid volume was noted in 10 of the 17 patients using AFI compared to 3 of the 17 patients using SDP (p<0.01). Decreased amniotic fluid volume was noted in 7 of the 17 AFI patients vs. 2 of the 17 patients using SDP (p<0.01). The int~apartum course of the patients with normal anmiotic fluid was compared to patients with low amniotic fluid, with respect to the presence of meconium, incidence of Caesarean section for fetal distress and evidence of intrapartum cord compromise. The results were: 12.2% vs. 82.3%, p<0.001, 3.3% vs. 52.9%, p<0,001 and 1.1% vs. 64.7%, p<0.0001, respectively. CONCLUSION: This study has shown that the four-quadrant technique--AInniotic Fluid Index is a far superior method of assessing low amniotic fluid volume compared to the standard SDP technique and should replace the single deepest pocket technique in the biophysical profile, especially in the pest-date gestation. GESTATION.
291 EFFECT OF OBESITY AND ANTERIOR PLACENTATION O N
AMNIOTIC FLUID INDEX MEASUREMENT. L.. PistoiaX, E Rimm x and M Gillieson. Dept Ob/Gyn, St Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA. OBJECTIVE: To determine whether evaluation of amniotic fluid volume using four quadrant index is affected by maternal obesity and anterior pLacentatiun. STUDY DESIGN: 456 Amniotic Fluid Index measurements were made in 275 gravidas. Median gestational age was 32.5 weeks. Multiple pregnancies and congenital anomalies were excluded. Abdominal wall thickness, Skin to Amniotic Cavity as well as amnioti¢ fluid depth for each uterine quadrant were measured. Cord was identified using color Doppler flow mapping. Placental site was recorded. Body Mass Index (8MI) was calculated at each visit as Kg/m2. 37 patients with BML >36 were classified as obese. Medical Complications and Demographic Data were recorded. Inter-observer variation was evaluated. Graphs of Amniotic Fluid Index for gestational age were developed. The influence on this measurement of all the data categories was evaluated by Linear Regression using SAS statistical software. RESULTS: Measurements in non-obese patients reproduced those of other workers. Amniotic Fluid Index peaked at 26 weeks, then decreased in approximately linear fashion. Amniotic Fluid Index was strongly correlated with maternal Diabetes, but also positively correlated with BM1, independent of the effect of Diabetes. Skin to amniotic cavity depth correlated with a decrease in Amniotic Fluid Index, but the effect was not strong. Anterior placentation was associated with greater Amniotic Fluid Index values. Inter-observer variability was not significant. CONCLUSIONS: Amniotic Fluid Index measurement is reproducible in obese patients, and is slightly increased, independent of diabetes. The potential for error associated with increased abdominal wall thickness is not of clinical significance, however anterior placentation causes systematic error in the measurement.
292 IS DALLY A N T E N A T A L T E S T I N G I N P A T I E N T S W I T H SEVERE PREECLAMPSlA EXCESSIVE? R.S. C h a r i . * S.A. Friedman, J.M. O'Brien, B.M. SibaL D e p a m n e n t of Ob~etrics and Gynecology, U u i v e , i t y o f Tennessee, M e m p h i s , Tennessee, O B J E C T I V E : T o determine whether daily antenatal testing it necessary in patients with severe preeclampsia managed expectantly, S T U D Y DESIGN: W e reviewed maternal-and neon~al ~ o f 68 patients with severe preeclampaia between 2 5 a n d 35 weeks' gestational age in w h o m delivery was delayed for at least 48 hours, R E S U L T S : T h e mean gestational age on admission was 3 0 . 4 + 2 . 8 weeks. All patients had a reassuring nonstress test (NST) and biophysical profile (BPP), along with an amniotic fluid index (AFI) 5 on admission. Subsequendy, each patient underwent daily BPP (induding NST) and AFI. Twenty pauents (29%) required delivery because o f n o n r e a , uring antenatal testmg which occurred within 24 houri of a normal test. Nonreauuring testlngwas defined as: recurrent late or severe variable decelerations o n NST; BPP -<4; AFI < 5 after 52 weeks or maximal vertical pocket < 2 cm before 52 weeks. Fetal Indications for Derive W ( N = 2 0 ) Indication for Delivery Decelerations on nonstress test Biophysical profile <-4 Low amniotlc fluid index
N u m b e r o f Patients 7 3 10
There were no intrauterine deaths or stillbirths. Two neonatal deaths occurred in severely premature infanss. C O N C L U S I O N S : Because optimizing neonatal outcome is the only reason to prolong pregnancy in patients with severe preeclampsia remote from term,-co/lfirmation o f fetal well-being is mandatory. Since 29% o f patients in our series required delivery because o f a deterioration in daily antenatal testing, we recommend daily testing in patients with severe preedampsia.
SPO Abstracts
J a n u a r y 1995 Am J Obstet Gynecol
289 AMNIOTIC FLUID INDEX DURING U N C O M P L I C A T E D TWIN PREGNANCY, TF P o r t ~ , GA Dildy, JR BluncharcP, N K Koc,henour, SL Clerk. Department of Ob/Gyn, University of Utah, Salt Lake City, and UVRMC, Provo, LIT. OBJECTIVE: To study the estimated gestational age (EGA) trends of anmiotic fluid index (AFI) in uncomplicated twin pregnancies. S T U D Y D E S I G N : A reWospective observational study of AFI's performed in uncomplicated twin pregnancies between 1985 and 1993.
Twins meeting the following uritm'iawere included: I) no matecnal medical or obstetricalcomplications. 2) normal growth of both twins by serial ultrasound,and 3) subjectively normal anmiotic fluid volume by ultrasound. AFI was measured by adding the deepest vertical pocket in four qua&ants, defined by the umbih'cus and linex nigra. R E S U L T S : 333 sets of twins were considered uncomplicated; 1088 AFFs were performed between 26 and 40.5 weeks: EGA .K28
Sth 6.0
1Oth
~th
9Oth
9$th
N
6.8 18.9 24.0 28.0 15 29 7.2 8.8 16.0 24.5 25.1 13 30 8.9 9.7 16.6 19.2 20.9 19 31 9.1 10.3 15.3 21.0 23.1 35 32 9.7 10.3 15.9 21.7 22.9 64 33 8.7 10.1 15.2 20.4 21.7 89 34 10.2 11.2 15.0 21.1 22.2 187 35 9.4 11.2 15.7 20.4 22.1 214 36 9.5 10.8 15.1 21.1 22.9 200 37 9.1 9.9 15.2 22.7 23.9 145 3g 8.5 9.6 14.3 20.3 22.4 77 39 7.2 9.5 14.3 20.2 21.0 20 >40 8.0 10.4 14.8 25.9 29.6 10 C O N C L U S I O N : The EGA trends of AFI are described for uncomplicated twin pregnancies. This information may be useful in monitoring complicated and uncomplicated twin gestations.
290 THE BIOPHYSICAL PROFILE: COMPARISON OF SINGLE DEEPEST POCKET TO FOUR-QUADRANT TECHNIQUE FOR AMNIOTIC FLUID ASSESSMENT IN THE POST-DATE YS Thornton. CA Rufx, CL Rosen x and UC Jackson, Morristown Memorial Hospital, NJ and Columbia University College of Physicians and Surgeons, New York, NY BACKGROUND: Amniotic fluid volume decreases as gestation reaches term and beyond. Diminished unmiotic fluid has been shown to be the best predictor of intrapartum distress. OBJECTIVE: To compare the standard single deepest pocket technique [SDP] to the four-quadrant technique-- the amniotic fluid index [AFI] in their ability to detect decreasing amounts of amniotlc fluid as part of the fetal biophysical profile in the post-date gestation. S T U D Y D E S I G N : A prospective study of weekly biophysics] profiles was conducted on 107 women beginning in their 41st week of gestation. Low amniotic fluid was classified as: M a r g i n a l fluid having a SDP <2 cm and >1 cm or the AFI <8 cm and ~.5 cm and decreased fluid was defined as the SDP <1 cm and the AFI <5 cm. Statistical analysis was performed by Z2, McNemar test and the Fishers exact test. R E S U L T S : Of the 107 patients, low amniotic fluid was observed in 17 patients using the AFI compared to only 5 patients using the SDP (1)<0.008). Marginal amniotic fluid volume was noted in 10 of the 17 patients using AFI compared to 3 of the 17 patients using SDP (p<0.01). Decreased amniotic fluid volume was noted in 7 of the 17 AFI patients vs. 2 of the 17 patients using SDP (p<0.01). The int~apartum course of the patients with normal anmiotic fluid was compared to patients with low amniotic fluid, with respect to the presence of meconium, incidence of Caesarean section for fetal distress and evidence of intrapartum cord compromise. The results were: 12.2% vs. 82.3%, p<0.001, 3.3% vs. 52.9%, p<0,001 and 1.1% vs. 64.7%, p<0.0001, respectively. CONCLUSION: This study has shown that the four-quadrant technique--AInniotic Fluid Index is a far superior method of assessing low amniotic fluid volume compared to the standard SDP technique and should replace the single deepest pocket technique in the biophysical profile, especially in the pest-date gestation. GESTATION.
291 EFFECT OF OBESITY AND ANTERIOR PLACENTATION O N
AMNIOTIC FLUID INDEX MEASUREMENT. L.. PistoiaX, E Rimm x and M Gillieson. Dept Ob/Gyn, St Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA. OBJECTIVE: To determine whether evaluation of amniotic fluid volume using four quadrant index is affected by maternal obesity and anterior pLacentatiun. STUDY DESIGN: 456 Amniotic Fluid Index measurements were made in 275 gravidas. Median gestational age was 32.5 weeks. Multiple pregnancies and congenital anomalies were excluded. Abdominal wall thickness, Skin to Amniotic Cavity as well as amnioti¢ fluid depth for each uterine quadrant were measured. Cord was identified using color Doppler flow mapping. Placental site was recorded. Body Mass Index (8MI) was calculated at each visit as Kg/m2. 37 patients with BML >36 were classified as obese. Medical Complications and Demographic Data were recorded. Inter-observer variation was evaluated. Graphs of Amniotic Fluid Index for gestational age were developed. The influence on this measurement of all the data categories was evaluated by Linear Regression using SAS statistical software. RESULTS: Measurements in non-obese patients reproduced those of other workers. Amniotic Fluid Index peaked at 26 weeks, then decreased in approximately linear fashion. Amniotic Fluid Index was strongly correlated with maternal Diabetes, but also positively correlated with BM1, independent of the effect of Diabetes. Skin to amniotic cavity depth correlated with a decrease in Amniotic Fluid Index, but the effect was not strong. Anterior placentation was associated with greater Amniotic Fluid Index values. Inter-observer variability was not significant. CONCLUSIONS: Amniotic Fluid Index measurement is reproducible in obese patients, and is slightly increased, independent of diabetes. The potential for error associated with increased abdominal wall thickness is not of clinical significance, however anterior placentation causes systematic error in the measurement.
292 IS DALLY A N T E N A T A L T E S T I N G I N P A T I E N T S W I T H SEVERE PREECLAMPSlA EXCESSIVE? R.S. C h a r i . * S.A. Friedman, J.M. O'Brien, B.M. SibaL D e p a m n e n t of Ob~etrics and Gynecology, U u i v e , i t y o f Tennessee, M e m p h i s , Tennessee, O B J E C T I V E : T o determine whether daily antenatal testing it necessary in patients with severe preeclampsia managed expectantly, S T U D Y DESIGN: W e reviewed maternal-and neon~al ~ o f 68 patients with severe preeclampaia between 2 5 a n d 35 weeks' gestational age in w h o m delivery was delayed for at least 48 hours, R E S U L T S : T h e mean gestational age on admission was 3 0 . 4 + 2 . 8 weeks. All patients had a reassuring nonstress test (NST) and biophysical profile (BPP), along with an amniotic fluid index (AFI) 5 on admission. Subsequendy, each patient underwent daily BPP (induding NST) and AFI. Twenty pauents (29%) required delivery because o f n o n r e a , uring antenatal testmg which occurred within 24 houri of a normal test. Nonreauuring testlngwas defined as: recurrent late or severe variable decelerations o n NST; BPP -<4; AFI < 5 after 52 weeks or maximal vertical pocket < 2 cm before 52 weeks. Fetal Indications for Derive W ( N = 2 0 ) Indication for Delivery Decelerations on nonstress test Biophysical profile <-4 Low amniotlc fluid index
N u m b e r o f Patients 7 3 10
There were no intrauterine deaths or stillbirths. Two neonatal deaths occurred in severely premature infanss. C O N C L U S I O N S : Because optimizing neonatal outcome is the only reason to prolong pregnancy in patients with severe preeclampsia remote from term,-co/lfirmation o f fetal well-being is mandatory. Since 29% o f patients in our series required delivery because o f a deterioration in daily antenatal testing, we recommend daily testing in patients with severe preedampsia.