# Clinical Cases: Fetal Assessment and Surveillance

## Case 1: Non-Reassuring Nonstress Test with Biophysical Profile

### Patient Demographics
- **Age:** 34 years
- **Sex:** Female
- **Occupation:** Elementary school teacher

### Chief Complaint
"I'm here for my weekly fetal testing because of my diabetes."

### History of Present Illness
The patient is G2P1 at 34 weeks gestation with pregestational type 2 diabetes. She has been on insulin throughout pregnancy with fair glycemic control (HbA1c 7.1% at 28 weeks). She presents for routine antenatal testing. She reports good fetal movement, no contractions, no vaginal bleeding, and no leakage of fluid.

### Past Medical History
- Type 2 diabetes mellitus x 6 years
- Obesity (BMI 34 kg/m2)
- Prior term vaginal delivery (infant 4,200 grams)

### Antenatal Testing Protocol
- Twice-weekly NST initiated at 32 weeks for pregestational diabetes

### Nonstress Test Results
**Initial NST (20 minutes):**
- Baseline fetal heart rate: 145 bpm
- Variability: Minimal (amplitude <5 bpm)
- Accelerations: None observed
- Decelerations: None
- Contractions: Occasional, irregular

**Extended NST (40 minutes):**
- Still no accelerations meeting criteria (15 bpm x 15 seconds)
- Variability remains minimal
- Interpretation: **Non-reactive NST**

### Vibroacoustic Stimulation
- Applied to maternal abdomen over fetal head
- No change in fetal heart rate pattern
- Still non-reactive after stimulation

### Next Step: Biophysical Profile

**BPP Results:**
| Component | Finding | Score |
|-----------|---------|-------|
| NST | Non-reactive | 0 |
| Fetal Breathing | Present (>30 seconds observed) | 2 |
| Fetal Movement | 3+ movements observed | 2 |
| Fetal Tone | Flexion/extension seen | 2 |
| Amniotic Fluid (MVP) | 4 cm (normal) | 2 |

**Total BPP Score: 8/10**

### Interpretation
- BPP 8/10 with non-reactive NST is considered **NORMAL**
- The non-reactive NST is likely due to fetal sleep state
- All other parameters normal, indicating adequate oxygenation
- No evidence of fetal hypoxia or acidosis

### Management
- Reassurance provided to patient
- Continue twice-weekly testing
- Return in 3-4 days for repeat NST/modified BPP
- Glucose log reviewed - adjustments made to evening NPH

### Teaching Points
- Non-reactive NST alone does not indicate fetal distress
- Fetal sleep cycles (20-40 minutes) are the most common cause of non-reactive NST
- BPP score of 8/10 with normal fluid is reassuring
- High negative predictive value: normal testing strongly predicts healthy fetus

### Clinical Image
![Nonstress Test](case_01_image.jpg)

**Image Description:** Fetal heart rate tracing demonstrating a non-reactive nonstress test with minimal variability and absence of accelerations over a 20-minute period. The tracing shows a stable baseline rate of approximately 145 bpm without decelerations.

**Attribution:** Educational illustration. Medical education resource demonstrating NST interpretation.

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## Case 2: Intrauterine Growth Restriction with Abnormal Umbilical Artery Doppler

### Patient Demographics
- **Age:** 28 years
- **Sex:** Female
- **Occupation:** Accountant

### Chief Complaint
"My doctor said the baby is measuring small and needs more testing."

### History of Present Illness
The patient is G1P0 at 30 weeks gestation, referred from her primary OB for suspected intrauterine growth restriction. At her 28-week visit, fundal height measured 24 cm (4 cm below expected). Growth ultrasound confirmed estimated fetal weight below the 5th percentile. She is now presenting for Doppler evaluation and fetal surveillance.

### Past Medical History
- Chronic hypertension on labetalol 200 mg twice daily
- Pre-pregnancy BMI 23 kg/m2

### Physical Examination
- BP: 142/92 mmHg (elevated from baseline 130/85)
- Fundal height: 26 cm at 30 weeks
- No edema, no hyperreflexia

### Ultrasound Findings

**Growth Parameters:**
- Estimated fetal weight: 1,050 grams (<3rd percentile for 30 weeks)
- Abdominal circumference: <3rd percentile
- Head circumference: 20th percentile
- Femur length: 18th percentile
- **Pattern:** Asymmetric IUGR (brain-sparing)

**Amniotic Fluid:**
- AFI: 6 cm (low-normal)

### Doppler Evaluation

**Umbilical Artery:**
- S/D ratio: 4.8 (elevated, >95th percentile)
- End-diastolic flow: **PRESENT** but reduced
- Interpretation: Elevated placental vascular resistance

**Middle Cerebral Artery:**
- Pulsatility index: Decreased (<5th percentile)
- Interpretation: Cerebral redistribution (brain-sparing)

**Cerebroplacental Ratio (CPR):**
- Calculated: 0.85 (abnormal, <1.0)

**Ductus Venosus:**
- A-wave: Present and forward (normal)

### Diagnosis
**Severe Early-Onset IUGR with Abnormal Dopplers**
- EFW <3rd percentile (severe IUGR)
- Asymmetric growth pattern
- Elevated UA resistance with present end-diastolic flow
- Evidence of fetal compensation (brain-sparing)
- Associated with chronic hypertension with superimposed preeclampsia workup initiated

### Management Plan

**Immediate:**
- Admit for observation and maternal evaluation
- Antenatal corticosteroids (betamethasone 12 mg IM x 2 doses)
- Preeclampsia labs (CBC, CMP, LDH, uric acid, 24-hour urine protein)
- Magnesium sulfate for neuroprotection given GA <32 weeks

**Surveillance Protocol:**
- Twice-daily NST
- Daily umbilical artery Doppler
- BPP every other day
- Ductus venosus Doppler daily

**Delivery Timing Discussion:**
- Current status (abnormal UA with PRESENT end-diastolic flow): aim for 32-34 weeks
- If ABSENT end-diastolic flow develops: 30-32 weeks
- If REVERSED end-diastolic flow: delivery after steroids at current GA
- If abnormal ductus venosus or BPP ≤6: delivery regardless of GA

### Hospital Course
- Preeclampsia labs confirmed superimposed preeclampsia (proteinuria 1.2 g/24 hours)
- Day 3: Developed absent end-diastolic velocity on UA Doppler
- Ductus venosus remained normal
- Decision: Continue monitoring with plan for delivery at 32 weeks

### Delivery
- Cesarean delivery at 32 weeks 0 days
- Male infant, 1,080 grams, Apgar 6/8
- NICU admission for prematurity; stable course

### Clinical Image
![Umbilical Artery Doppler](case_02_image.jpg)

**Image Description:** Umbilical artery Doppler waveform showing elevated S/D ratio with present but reduced end-diastolic flow, indicating increased placental vascular resistance consistent with placental insufficiency in the setting of intrauterine growth restriction.

**Attribution:** Image from Radiopaedia. Educational case. Licensed under CC BY-NC-SA 3.0. Source: https://radiopaedia.org/articles/umbilical-artery-doppler

---

## Case 3: Decreased Fetal Movement with Oligohydramnios

### Patient Demographics
- **Age:** 32 years
- **Sex:** Female
- **Occupation:** Nurse

### Chief Complaint
"I haven't felt the baby move as much today. Something feels wrong."

### History of Present Illness
The patient is G3P2 at 39 weeks 2 days gestation with an uncomplicated pregnancy. She reports that over the past 24 hours, she has noticed significantly decreased fetal movement. She normally feels the baby move vigorously, especially in the evening, but last night and today she has felt only occasional, weak movements. She attempted kick counts this morning but only felt 4 movements in 2 hours (goal is 10 movements in 2 hours). She denies contractions, vaginal bleeding, or leakage of fluid.

### Past Medical History
- Two prior uncomplicated term vaginal deliveries
- No chronic medical conditions

### Physical Examination
- **Vital Signs:** BP 118/72 mmHg, HR 78 bpm, afebrile
- **Abdomen:** Gravid, non-tender, vertex by Leopold maneuvers
- **Cervix:** Closed, 30% effaced, -3 station

### Initial Evaluation: Nonstress Test

**NST Results:**
- Baseline fetal heart rate: 155 bpm
- Variability: Minimal to absent
- Accelerations: None in 40 minutes
- Decelerations: Two variable decelerations noted
- Interpretation: **Non-reactive with variable decelerations**

### Concern Raised - Proceed to BPP

**Biophysical Profile:**
| Component | Finding | Score |
|-----------|---------|-------|
| NST | Non-reactive | 0 |
| Fetal Breathing | None observed in 30 minutes | 0 |
| Fetal Movement | 2 movements only | 0 |
| Fetal Tone | One extension noted | 2 |
| Amniotic Fluid (MVP) | 1.5 cm (**Oligohydramnios**) | 0 |

**Total BPP Score: 2/10**

### Diagnosis
**Non-reassuring Fetal Status with BPP 2/10**
- Critically low BPP score indicating probable fetal asphyxia
- Oligohydramnios suggesting chronic placental insufficiency
- Variable decelerations may indicate cord compression

### Management - Emergent Delivery

**Immediate Actions:**
- Continuous fetal monitoring initiated
- IV access established, type and crossmatch
- Obstetric team and anesthesia notified
- NICU alerted
- Decision: Emergent cesarean delivery

**Rationale:**
- BPP 2/10 at term is an indication for delivery
- Attempting induction would be inappropriate given the non-reassuring status
- Cesarean provides the most expeditious delivery

### Delivery Outcome
- Emergent cesarean delivery performed
- Female infant, 3,020 grams
- Apgars 4/6/8 (1, 5, and 10 minutes)
- Cord gases: pH 7.12, base excess -10 (mild metabolic acidosis)
- Nuchal cord x 2 noted at delivery (likely cause of oligohydramnios from cord compression and variable decelerations)
- NICU observation for 24 hours; discharged to well-baby nursery

### Placental Pathology
- Placenta sent for evaluation
- Findings: Small infarcts, accelerated maturation
- Consistent with chronic uteroplacental insufficiency

### Teaching Points
- Decreased fetal movement is an important warning sign requiring prompt evaluation
- Low threshold for evaluation when patient reports decreased movement
- BPP ≤4 indicates high probability of fetal asphyxia
- Oligohydramnios at term warrants delivery consideration
- Variable decelerations suggest umbilical cord compression
- Normal testing has high negative predictive value, but abnormal testing requires action

### Clinical Image
![Biophysical Profile](case_03_image.jpg)

**Image Description:** Ultrasound image demonstrating severe oligohydramnios with maximum vertical pocket of less than 2 cm. The fetal structures appear crowded with minimal amniotic fluid surrounding the fetus, consistent with chronic placental insufficiency.

**Attribution:** Educational illustration. Public domain medical education resource.