2. BPP & IGUR
• Meaning
• Indications, patient preparation and scanning technic for
BPP
• Components of BPP
• Factors affecting BPP
• Clinical applications
• IUGR
• Reference
3. MEANING OF BPP
• BPP is a prenatal test used to assess fetal well-being, typically
performed during the third trimester of pregnancy.
• It combines ultrasound with a non-stress test (NST) to evaluate key
indicators of fetal health, such as movement, muscle tone, breathing,
and the amount of amniotic fluid surrounding the baby.
• The goal is to detect any signs of fetal distress, especially in high-risk
pregnancies, so that appropriate medical interventions can be
considered if necessary.
4. CONT.
• The biophysical profile (BPP) is based on the concept that
fetal breathing, movement and tone is mediated by
neurological pathways and therefore reflect the fetal CNS
status at the time of the examination.
• Amniotic fluid level is a measure of chronic asphyxia or
placental function.
5. When is BPP done?
• BPP is typically performed during the third trimester of
pregnancy, usually after 32 weeks gestation.
• However, it may be done earlier (as early as 24-26
weeks) if there are concerns about the health of the fetus
or if the pregnancy is considered high-risk.
8. Basis of the BPP
• Hypoxemia and acidemia have interference with central nervous
system (CNS)
• oligohydramnios with fetal hypoxemia is as a result of blood flow
redistributed away from the fetal kidneys and viscera in favor of
the brain, heart, and adrenal glands.
• When activities of these oxygen-dependent centers are observed,
it can be assumed that brain function is normal and systemic
hypoxia is not present
• If one or more of the BPP activities is not observed, hypoxemia
must be assumed to be the cause of the absence of that activity.
9. Patient preparation
• No definite preparation
• Explain the procedure and comforting the patient
• Emptying urinary bladder can give accurate
measurements
• Heavy meal should be given to the mother for good fetal
movements
• Relaxation and patience
10. Scanning techniques
• Same as 3rd trimester obstetric ultrasound scanning
• Four parameters as the protocol indicate
• Highly depending on fetal condition and sleep stage
• It may take 10 minutes or 2hrs
11. Components of BPP
• Fetal breathing movements
• Fetal movements
• Fetal tone
• Amniotic fluid volume
• Fetal heart rate /Non-stress test
12. Scoring on biophysical profile
• The scoring of a Biophysical profile involves assessing
five different components, each of which is assigned a
score of 0 or 2 points, based on the fetus's performance
• And Aatotal score of 10 is possible
13. Fetal breathing movements (2 points )
Score 2
• At least one episode of rhythmic fetal breathing lasting at
least 30 seconds within a 30-minute observation period.
Score 0
• Absence of fetal breathing movements or breathing
movements lasting less than 30 seconds.
14. Fetal movements (2 points)
Score 2
• At least three discrete body or limb movements within
the 30-minute observation period.
Score 0
• Fewer than three movements.
15. Fetal tone (2 points)
Score 2
• At least one episode of active extension with return to
flexion of the fetal limb(s) or trunk (opening and closing
of the hand)
Score 0:
• Slow extension/flexion or absence of movement.
16. Amniotic fluid volume (2 points)
Score 2
• At least one pocket of amniotic fluid that is 2 cm in
vertical diameter or more
Score 0
• Absence of an adequate pocket of amniotic fluid
17. Non-stress test (2 points)
Score 2:
• The baby’s heart rate accelerates twice or more within 20
minutes, lasting at least 15 seconds, and rising by at least
15 beats per minute (for fetuses >32 weeks gestation).
Score 0
• No heart rate accelerations or an abnormal response.
18. Total score interpretation
Score of 8-10 (Normal)
• Indicates a healthy, well-oxygenated fetus that is not in
distress
• This is considered a reassuring result, especially if there
is adequate amniotic fluid volume.
• No immediate intervention is typically required, though
routine monitoring may continue depending on the
pregnancy.
19. Score of 6 (equivocal or borderline)
• This score may suggest that further evaluation is
needed, as it indicates a potential concern.
• If the amniotic fluid volume is normal but other
components score lower, additional testing or closer
monitoring may be recommended.
• If amniotic fluid is low (oligohydramnios), delivery may
be considered, depending on the gestational age
20. Score of 4 or lower (abnormal)
• Indicates a high likelihood of fetal distress, especially if the
amniotic fluid volume is low.
• Immediate action is often required, which may include
repeating the BPP test or even delivering the baby,
depending on the severity of the findings and gestational
age.
• A score of 4 or lower is considered a "non-reassuring" result
21. The parameter is scanned as follows
Fetal gross body breathing movements:
• Presence of one or more episode
• Extension and flexion of the fetal extremity
• During 30 minutes observation
• Spine in position of extension and flexion
22. Fetal breathing movements
• Presence of at least one episode of sustained fetal
breathing at least 30 minutes duration
• Monitor outward and inward movements of the chest
• Monitor cranio-caudal movements of the kidney
23. Fetal tone
• One or more episode of fetal extremity with return to
flexion, 30 minutes observation
Amniotic fluid
• The deepest pocket should measure at least 2cm on two
perpendicular planes
26. Factors affecting biophysical profile
Maternal Factors
• Maternal position, the mother's position during the test
• Maternal obesity, excess maternal body weight or obesity can
sometimes make it difficult to obtain clear ultrasound images.
• Dehydration, low maternal hydration can affect amniotic fluid
levels.
• Medications, certain medications taken by the mother like
sedatives or narcotics) can reduce fetal movement and breathing,
potentially affecting BPP results.
27. Cont.
Fetal factors
• Fetal sleep cycles, babies have periods of sleep during
which they are less active
• Fetal activity variability, some fetuses may naturally be
more or less active.
Gestational age
• Early gestation, if the BPP is performed before 32 weeks
of pregnancy, fetal movements and breathing patterns
may not be as regular, leading to lower scores.
28. Cont.
Amniotic fluid variations
• Hydration status, maternal hydration can impact amniotic fluid
levels. If a mother is dehydrated, amniotic fluid levels might
appear lower than they actually are
• Fetal urinary output, since amniotic fluid is partially produced by
fetal urine, any issue affecting fetal kidney function or urinary
output can result in lower fluid levels, affecting the BPP score.
29. Cont.
Fetal or placental complications
• Placental insufficiency, if the placenta is not providing enough
oxygen and nutrients to the baby, it can affect fetal movements,
breathing, and overall activity.
• Fetal health conditions, if the baby has a medical condition, such
as growth restriction (IUGR) or congenital abnormalities, it may
lead to lower scores in fetal tone, movement, or breathing
patterns.
30. Cont.
Maternal health conditions
• Preeclampsia, mothers with preeclampsia or high blood pressure
might have abnormal placental function, which can affect fetal
oxygenation and result in reduced fetal movements or abnormal
BPP results.
• Gestational diabetes, poorly controlled diabetes can lead to
excessive amniotic fluid (polyhydramnios) or fetal complications
that can affect BPP scores.
33. Clinical application
• BPP is used to predict the presence or absence of fetal
asphyxia.
• Both the gestation age at which testing is begun and the
testing frequency will differ depending on both the
maternal and fetal risk factors.
34. Assessment of fetal well-being
• Routine monitoring in high-risk pregnancies, BPP is commonly
used to monitor fetuses in high-risk pregnancies, such as those
with,
• Preeclampsia or gestational hypertension.
• Diabetes (gestational or pre-existing).
• Fetal growth restriction (IUGR).
• Oligohydramnios (low amniotic fluid) or polyhydramnios
(excess amniotic fluid).
• Chronic maternal conditions, such as kidney disease or
autoimmune disorders.
36. INTRAUTERINE UTERINE GROWTH
RESTRICTION
• Intrauterine growth restriction (IUGR) or fetal growth restriction (FGR) is defined as
an estimated fetal weight (EFW) and/or abdominal circumference (AC) at one point
in time during pregnancy being below the 10th percentile for gestational age with
deranged Doppler parameters .
• An IUGR can be broadly divided into two main types:
• type I: symmetrical intrauterine growth restriction
• type II: asymmetrical intrauterine growth restriction
37. SGA VS. IUGR
• Small for Gestational Age (SGA)
• Fetuses with birth weight < 10th
percentile for
gestational age in the absence of a pathological
process.
• (constitutionally small due to maternal height,weight,
ethnicity and parity)
• Intrauterine fetal growth restriction (IUGR)
• Fetuses with birth weight < 10th
percentile for
gestational age due to a pathological process.
38. IUGR VS. SGA
• Not all low birth weight babies have IUGR
• A certain number of fetuses at or below the
10th
percentile may just be constitutionally
small & not growth restricted (SGA)
• There is a possibility of misclassifying normally
nourished, healthy, but constitutionally small,
fetuses as growth restricted.
39. PHASES OF FETAL
GROWTH
• First 16 weeks: mostly cellular hyperplasia
• 16-32 weeks: both hyperplasia and hypertrophy
• >32 weeks: mostly hypertrophy. In addition,
rapid accumulation of fat, muscle and connective
tissue occurs
Thus: early growth restriction will affect cell
numbers and have a global (symmetrical) effect.
Later cell size will be affected.
44. MATERNAL CAUSES
• Low pre-pregnancy weight, poor
gestational weight gain, malabsorption,
malnutrition
• Short interpregnancy interval
• Extremes of maternal age
• Severe malnutrition
• Teratogens (medications, cigarette
smoking , Alcohol, Drugs, Infections)
45. FETAL CAUSES
• Fetal infection (Malaria, CMV,Toxoplasmosis,
Rubella,Varicella, Syphilis, Herpes)
• Fetal genetic abnormalities (most commonly
trisomy 18)
• Fetal structural anomalies e.g. Congenital
cardiac anomalies
• Multiple gestations (inability to meet the
nutritional needs of multiple fetuses and
pregnancy complications more common in
multiple gestations (e.g., preeclampsia,TTS)
46. TYPES OF IUGR
1. Symmetrical: Early onset, Intrinsic
2. Asymmetrical: Late onset, metabolic
47. SYMMETRICAL IUGR
• It is a type of intrauterine growth restriction (IUGR)
where all fetal biometric parameters tend to be less
than expected (below the 10th percentile) for the given
gestational age. Both length and weight parameters are
reduced.
All sonographic biometric parameters tend to be
symmetrically reduced.Therefore, fetuses have normal
or near-normal:
HC (head circumference) : AC (abdominal
circumference) ratio
FL (femoral length) : AC (abdominal circumference) ratio
48. ASYMMETRICAL IUGR
• Asymmetrical intrauterine growth restriction is a
type of intrauterine growth restriction (IUGR)
where some fetal biometric parameters are
disproportionately lower than others.It tends to
present more in the 3rd trimester (later than the
symmetrical IUGR pattern) and is the more
common of the two primary types of IUGR.
• placental insufficiency: one of the commonest
causes of asymmetrical IUGR and pre-eclampsia
49. ULTRASOUND FEATURES OF ASMMETRICAL
IUGR.
• Fetal abdominal circumference (AC) is classically reduced out of proportion
to other fetal biometric parameters and is below the 10th percentile
• Certain fetal biometric parameters such as the biparietal diameter (BPD)
and head circumference (HC) may be normal.
• Increased HC:AC ratio
• Fetal tachycardia (may be present in up to 50% of cases 4)
• Oligohydramnios may be present as an additional sonographic feature.
51. DOPPLER FEATURES.
• Umblical arterial doppler assesment.
It is used to survey fetal well-being in the third trimester of pregnancy. Abnormal
umbilical artery Doppler is a marker of placental insufficiency and consequent
intrauterine growth restriction (IUGR) or suspected pre-eclampsia.
• wave form.
The umbilical arterial waveform usually has a "sawtooth" pattern with flow always in the
forward direction, that is towards the placenta. An abnormal waveform shows absent or
reversed diastolic flow. Before the 15th week, the absence of diastolic flow may be a
normal finding .
52. • In growth-restricted fetuses and fetuses developing intrauterine distress, the
umbilical artery blood velocity waveform usually changes in a progressive manner
as below
• reduction in end-diastolic flow:
• absent end-diastolic flow (AEDF):
• reversal of end-diastolic flow (REDF)
56. UTERINE ARTERY ASSESMENT.
• In a non-gravid state and at the very start of pregnancy the flow in the uterine artery
is of high pulsatility with a high systolic flow and low diastolic flow. A physiological
early diastolic notch may be present.
• Resistance to blood flow gradually drops during gestation as a greater trophoblastic
invasion of the myometrium takes place. An abnormally high resistance can persist in
pre-eclampsia and IUGR. If resistance is low, it has an excellent negative predictive
value with a <1% chance of developing either pre-eclampsia or having IUGR. A high
resistance often equates to a 70% chance of pre-eclampsia and 30% chance of IUGR.
57. ABNORMAL UTERINE PATTERNS
• persistence of a high resistance flow throughout pregnancy
• persistence of notching throughout pregnancy
• reversal of diastolic flow throughout pregnancy: severe state
59. MIDDLE CEREBRAL ARTERY (MCA)
• In the normal situation the fetal MCA has a high resistance
flow which means there is minimal antegrade flow in fetal
diastole
• In pathological states this can turn into a low resistance flow
mainly as a result of the fetal head sparing theory
• paradoxically in some situations such as with severe
cerebral edema, the flow can revert back to a high
resistance pattern when the pathology has not yet resolved
- this is a very poor prognostic sign
• cerebroplacental ratio: >1:1 is normal and <1:1 is abnormal
• it can occasionally show end-diastolic flow reversal, a non-
pathological finding that is usually due to increased
intracranial pressure mostly by probe compression
62. Figure
A. The normal middle cerebral artery
flow pattern has relatively
little diastolic flow
B. With progressive placental
dysfunction there may
be an increase in the diastolic velocity,
resulting in a decrease in the
Doppler index (Brain sparing,
With marked brain sparing, the
systolic down slope of the waveform
becomes smoother so that
the waveform almost resembles that of
the umbilical artery
D. The associated rise in the mean
velocity results in a marked decline in
the Doppler index
64. Confirmation of IUGR
• The best method to confirm whether a fetus has IUGR or
is constitutionally small is to combine an evaluation of
all parameters.
• A normal umbilical artery, maternal uterine artery, and
fetal middle cerebral artery help in evaluating the fetus
that is well and normal but just small, rather than small
secondary to IUGR.
65. Macrosomia
• Macrosomia is traditionally defined as a birth weight of 4000 g or
greater, or above the 90th percentile for estimated gestational age.
With respect to delivery, however, any fetus that is too large for the
pelvis through which it must pass is macrosomic.
• Macrosomia has shown to be 1.2 to 2 times more frequent than normal
in women who are multiparous, are 35 years or older, have a
prepregnancy weight of more than 70 kg (154 lb),have pregnancy
weight gain of 20 kg (44 lb) or greater, have a postdate pregnancy, or
have a history of delivering an LGA fetus.
• Macrosomia is also a common result of poorly controlled maternal
diabetes mellitus.
66. CLINICAL SIGNIFICANCE OF MACROSOMIA
Maternal complications.?
.protracted or arrested labour.
.genital tract lacerations.
.postpartum hemorrhage
.uterine rupture
67. CONT.
Fetal and neonatal risks.
.shoulder dystocia leading to birthtrauma(brachial plexus injury or fractures)
.neotal respiratory distress
.later development of impaired glucose tolerance and diabetes.
68. QUIZ
1. Define the following terms
a) Small for gestation age
b) Intrauterine growth restriction
c) Macrosomia
2. List the risk factors for IUGR
3. Outline how IUGR can be diagnosed
4. List five complication asociated with IUGR
69. 5. List risk factors for macrosomia
6. Outline complications associated with macrosomia
#36:It refers to acondition in which afetus is smaller than expected for the number of weeks of pregnancy, typically because it is not growing at anormal rate inside the womb.
#37:Intrauterine fetal growth restriction (IUGR) refers to the fetus who does not achieve the expected in utero growth potential due to genetic or environmental factors (not constitutionally small due to maternal height, weight, ethnicity and parity)
#42:the placenta is responsible for providing the baby with oxygen and nutrients. if it doesnt function properly, it can reduce the supply of these vital substances casuing poor fetal growth.
#43:the above conditions affect the mothers ability to provid nutrients and oxyen to the fetus.
#47:
1/3 of all cases
Fetus is proportionally small
Diagnosed early
fetuses with this type of IUGR pattern may present at an earlier stage in gestation compared with the asymmetrical IUGR pattern.
#48:
Slow AC growth vs normal HC and FL
(glycogen utilization by liver, liver shrinkage, decreased AC; preferential shunting to brain thus maintained HC)
#52:Perinatal mortality increases significantly in fetuses with absent EDF (9-41%) and reversed EDF (33-73%) in the umbilical artery
#59:In a situation of chronic fetal hypoxemia,
the fetus redistributes its cardiac output to maximize the oxygen supply to brain by vasodilation of the cerebral arteries thereby causing a decrease in the PERIPHERAL and PLACENTAL circulations.
cerebral placental ratio is the ratio between mca and umblical artery doppler pulsatilty indices. high cpr indicates normal or welll compensated bloodflow to the fetal brain and placenta. low cpr indicates that the fetus may be experiencing placental insuffieciency with blood being preferentially directed to the brain.
