125  Fetal Biophysical Profile

537

SECTION FOUR
Other
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125  Fetal Biophysical Profile

CHRISTINA S. HAN  |  LAWRENCE D. PLATT

Introduction ultrasound (US) and cardiotocography, also known as a nonstress

test (NST). The US component combines the assessment of four
The biophysical profile (BPP) was first described in 1980 as a activities: fetal movement, fetal breathing, and tone over a
method to quantify and standardize antepartum fetal evaluation.1 30-minute period, along with amniotic fluid assessment. The
The full BPP test is performed using a combination of real-time NST component continuously monitors the fetal heart rate and
538 PART 13  Miscellany  •  SECTION FOUR Other

TABLE 125.1  INDICATIONS FOR ANTEPARTUM Fetal hypoxemia/asphyxia

FETAL TESTING*
Maternal Conditions Pregnancy-Related Conditions
• Pregestational diabetes • Gestational hypertension CNS cellular dysfunction Aortic chemoreceptor stimulation
mellitus • Preeclampsia
• Hypertension • Decreased fetal movement
• Systemic lupus • Gestational diabetes
erythematosus mellitus (poorly controlled Reflex late Reflex redistribution of
• Chronic renal disease or medically treated) Hypotonia
decelerations cardiac output
• Antiphospholipid syndrome • Oligohydramnios
• Hyperthyroidism (poorly • Fetal growth restriction
controlled) • Late-term or postterm
Increased flow to brain,
• Hemoglobinopathies (sickle pregnancy Absent fetal breathing
cell, sickle cell–hemoglobin • Isoimmunization adrenals, heart, placenta
C, or sickle cell–thalassemia • Previous fetal demise
disease) (unexplained or recurrent
• Cyanotic heart disease risk) Decreased flow to kidneys,
Absent fetal movement
• Monochorionic multiple lungs, gut, liver
gestation (with significant
growth discrepancy)

*These indications are considered relative, because antepartum fetal Nonreactive NST
surveillance results have not been definitively demonstrated to
improve perinatal outcome.
Fig. 125.1  Fetal functional responses to hypoxemia. CNS, Central
nervous system; NST, nonstress test.

TABLE 125.2  BIOPHYSICAL PROFILE SCORING

SYSTEM only NST and amniotic fluid assessment, has also been found
Parameter Description Score to have good predictive value, and is commonly used.
A normal BPP is considered highly reassuring, as reflected
Breathing ≥1 episode of ≥30 seconds in 30 2
minutes. Hiccups are considered in the low false-negative rate of antepartum fetal surveillance,
breathing activity. defined as the incidence of stillbirth occurring within 1 week of
Movement At least three body or limb movements 2 a normal test result.4 The negative predictive value is 99.8% for
in 30 minutes. the NST and is greater than 99.9% for the contraction stress
Tone At least one episode of active 2 test, BPP, and modified BPP.
extension/flexion in 30 minutes.
Amniotic fluid A single 2 cm × 2 cm pocket. 2
Nonstress test Two accelerations >15 beats per 2 Disorder
minute of at least 15 seconds
duration.
Decreased fetal breathing.

DEFINITION
uterine activity over 20+ minutes. Relative indications for Decreased fetal breathing is defined by the absence of at least
antepartum fetal surveillance, including BPP, are listed in Table one 30-second segment of continuous fetal breathing over a
125.1. The BPP is usually initiated only after 32 weeks for patients 30-minute real-time examination. Some experts accept fetal
at risk of stillbirth.2,3 In patients with multiple or severe comor- hiccups as equivalent to breathing, although no data are available
bidities, BPP testing may begin at even earlier gestational ages on the reliability of this sign.
if delivery would be considered for fetal benefit.4
Five variables—breathing, movement, tone, amniotic fluid PREVALENCE AND EPIDEMIOLOGY
volume, and NST—are included in the test. Table 125.2 describes
the specific parameters required to obtain a score of 2 in each Fetal breathing occurs intermittently and usually develops around
category. A reassuring BPP score is 8 or 10 out of 10, whereas a 20 weeks’ gestation,8 fluctuating throughout the day. In a study
score of 6 is equivocal, and 4 or less is abnormal.4 These param- continuously evaluating fetal breathing behavior in 11 healthy
eters are indicators of a functional fetal central nervous system women at 34–35 weeks of gestation, breathing frequency changes
and absence of hypoxemia (Fig. 125.1).5,6 were seen with meals (increase 2–3 hours following consumption)
The composite score is better at differentiating normal from and during the night (between 1 and 7 a.m.).9 Fetal gross move-
compromised fetuses than any single parameter. In a study ments and breathing movements are present for periods of 20–60
evaluating patients undergoing elective prelabor cesarean delivery, minutes out of every 1–1.5 hours of observation time, likely
predelivery BPP yielded 90% sensitivity, 96% specificity, and reflecting biologic changes of sleep state in the fetus.
82% positive and 98% negative predictive value in predicting
fetal acidosis, defined by an umbilical cord arterial pH <7.20.7 ETIOLOGY AND PATHOPHYSIOLOGY
The efficacy of composite BPP to indicate fetal acidosis was
found to be superior to the 1- and 5-minute Apgar scores in Factors implicated in altered fetal breathing are noted in Table
sensitivity and positive predictive value. A modified BPP, using 125.3. When a fetus is acidotic, the first fetal behavior changes
 125  Fetal Biophysical Profile 539

TABLE 125.3  FACTORS AFFECTING FETAL Disorder

BREATHING
Decreased fetal movement and tone.
Increased Breathing Decreased Breathing No Change
• Meal consumption • Magnesium sulfate • Caffeine DEFINITION
• Maternal glucose • Alcohol
level rise • Nicotine Decreased fetal movement is defined by less than three body or
• Increased • Narcotics
gestational age • Benzodiazepines
limb movements in a 30-minute period. Decreased tone is defined
labor by absence of an active extension/flexion motion in limbs or
• Premature rupture hands in a 30-minute period.
of membranes
• Intraamniotic
infection PREVALENCE AND EPIDEMIOLOGY
Fetal movement and tone are also intermittent in normal fetuses,
developing around 7.5 and 9 weeks, respectively.11 The centers
are a nonreactive NST and loss of fetal breathing motion.7 In regulating fetal movement and tone have a higher threshold for
animal models, fetal breathing movements cease abruptly when hypoxemia than those for fetal breathing or heart rate accelera-
the tissue PO2 falls by about 8 to 10 torr.10 tions. Therefore loss of fetal breathing and heart rate accelerations
predictably occur earlier in a hypoxemic event, when pH is less
MANIFESTATIONS OF DISEASE than 7.2, followed by loss of tone and movement when pH is
less than 7.1.7
Clinical Presentation
Absence of rhythmic movement of the chest, diaphragm, and ETIOLOGY AND PATHOPHYSIOLOGY
abdominal wall, occurring at a frequency of 1/sec (Video 125.1).
The most common cause of decreased fetal movement and tone
Imaging Technique and Findings is a period of fetal sleep. In fetuses between 36 and 42 weeks the
Ultrasound.  US real-time imaging is used to visualize fetal chest mean duration of fetal sleep is 20 minutes, and episodes can
and abdominal walls, and diaphragmatic motion. The image extend up to 40 minutes.12 Other common causes of decreased
can be obtained in the coronal, sagittal, or less ideally, transverse fetal movement are steroid administration, labor, and smoking.
plane. M-mode can also be used to document wall motion. A
clip or video of the fetal breathing motion should be recorded MANIFESTATIONS OF DISEASE
when technology permits (see Video 125.1). It is important to
ensure that the movement noted is not from maternal breathing Clinical Presentation
motions or fetal cardiac activity moving the diaphragm. Patients may subjectively describe decreased fetal movement. In
those performing fetal kick counts, they may note an increase
Differential Diagnosis From in time to achieve 10 kicks, which should always prompt some
other testing for fetal well-being.
Imaging Findings
Fetal sleep cycle or other external factors decreasing movement. Imaging Technique and Findings
(See Table 125.3) Ultrasound.  US real-time imaging is used to visualize fetal tone
and movement, as described previously.

Synopsis of Treatment Options Differential Diagnosis From

PRENATAL Imaging Findings
Decision on expectant management, repeat surveillance or delivery Fetal sleep should be considered. The same factors that cause
should be based made on the composite BPP score, factoring in decreased fetal breathing may also affect fetal movement.
gestational age and other relevant clinical parameters.

POSTNATAL
Synopsis of Treatment Options
PRENATAL
Neonatal resuscitation may be required in fetuses delivered for
abnormal BPP. Delivery plans should be coordinated with a Decision on expectant management, repeat surveillance, or
pediatric resuscitation team. delivery should be based made on the composite BPP score,
factoring in gestational age and other relevant clinical
parameters.

WHAT THE REFERRING PHYSICIAN NEEDS TO KNOW POSTNATAL

The examination should continue until completion of 30 minutes if Neonatal resuscitation may be required in fetuses delivered for
the fetus does not meet criteria, to allow for completion of a sleep
cycle.
abnormal BPP. Delivery plans should be coordinated with a
pediatric resuscitation team.
540 PART 13  Miscellany  •  SECTION FOUR Other

Imaging Technique and Findings

WHAT THE REFERRING PHYSICIAN NEEDS TO KNOW
Ultrasound.  US real-time imaging is used to visualize fetal BPP
The examination should continue until completion of 30 minutes if parameters, as described previously.
the fetus does not meet criteria, to allow for completion of a sleep
cycle.
Synopsis of Treatment Options
PRENATAL
TABLE 125.4  PERINATAL MORTALITY AND
BIOPHYSICAL PROFILE14 A BPP of 6/10 without oligohydramnios can be repeated in 24
hours. A BPP of 6/10 with oligohydramnios requires evaluation
BPP Score Perinatal Mortality per 1000 of gestational age, maternal comorbidities, obstetric factors, and
8–10 1.86 maternal-fetal risks to continuation of pregnancy. Clinical judg-
6 9.76 ment following a score of 6/10 should be based on the risk-benefit
4 26.3 trade-off between expectant management and immediate delivery.
2 94.0 A BPP of 0 to 4/10 usually requires immediate delivery. Route
0 285.7 of delivery will depend on whether cervix is favorable, parity,
duration of impending labor and delivery, and fetal ability to
BPP, Biophysical profile.
tolerate labor.

Disorder POSTNATAL
Abnormal BPP result. Neonatal resuscitation may be required in fetuses delivered for
abnormal BPP. Delivery plans should be coordinated with a
pediatric resuscitation team.
DEFINITION
A BPP score of 6/10 is most commonly caused by deductions
from fetal breathing movement and nonreactive fetal heart tracing. WHAT THE REFERRING PHYSICIAN NEEDS TO KNOW
However, oligohydramnios may replace one of the other deduc- The examination should continue until completion of 30 minutes if
tions. A BPP of 6/10 without oligohydramnios is considered an the fetus does not meet criteria, to allow for completion of a sleep
equivocal test. A BPP of 6/10 with oligohydramnios is a pathologic cycle.
result, with increased risk of fetal asphyxia within one week of
test result.13 A BPP score of 0, 2 or 4/10 is considered abnormal,
and delivery is usually indicated, although management decisions KEY POINTS
at early gestational age may be individualized because of the
risks of extreme prematurity.4 • Multiple indications exist for use of BPP in antepartum
surveillance.
• The examination should continue until completion of 30
PREVALENCE AND EPIDEMIOLOGY minutes if the fetus does not meet criteria, to allow for
completion of a sleep cycle.
Perinatal mortality associated with each BPP result is listed in • External factors, including medications, exposures, and
Table 125.4. gestational age, may affect BPP scores.
• Perinatal mortality and morbidity is inversely proportional to
BPP score.
ETIOLOGY AND PATHOPHYSIOLOGY
Loss of fetal breathing, movement, or tone are described earlier. SUGGESTED READINGS
Etiology of oligohydramnios is described in Chapter 120. ACOG Practice Bulletin Number 145: antepartum fetal surveillance. Obstet
Gynecol. 2014;124:182-192.
MANIFESTATIONS OF DISEASE Manning FA. Fetal biophysical profile: a critical appraisal. Clin Obstet Gynecol.
2002;45(4):975-985.
Clinical Presentation
Diagnosis is made during routine testing for high-risk indications, All references available online at
or upon patient complaint of decreased fetal movement. www.expertconsult.com
 125  Fetal Biophysical Profile 540.e1

REFERENCES 8. Fox HE, Hohler CW. Fetal evaluation by real-time imaging. Clin Obstet
Gynecol. 1977;20(2):339-349.
1. Manning FA, Platt LD, Sipos L. Antepartum fetal evaluation: development 9. Patrick J, Natale R, Richardson B. Patterns of human fetal breathing activity
of a fetal biophysical profile. Am J Obstet Gynecol. 1980;136(6):787-795. at 34 to 35 weeks’ gestational age. Am J Obstet Gynecol. 1978;132(5):
2. Pircon RA, et al. Antepartum testing in the hypertensive patient: when to 507-513.
begin. Am J Obstet Gynecol. 1991;164(6 Pt 1):1563-1569, discussion 10. Boddy K, et al. Foetal respiratory movements, electrocortical and cardio-
1569-1570. vascular responses to hypoxaemia and hypercapnia in sheep. J Physiol.
3. Rouse DJ, et al. Determinants of the optimal time in gestation to initiate 1974;243(3):599-618.
antenatal fetal testing: a decision-analytic approach. Am J Obstet Gynecol. 11. Fitzgerald JE, Windle WF. Some observations on early human fetal move-
1995;173(5):1357-1363. ments. J Comp Neurol. 1942;76:159-167.
4. ACOG. Practice bulletin no. 145: antepartum fetal surveillance. Obstet 12. Pillai M, James D. Behavioural states in normal mature human fetuses.
Gynecol. 2014;124(1):182-192. Arch Dis Child. 1990;65(1 Spec No):39-43.
5. Humphrey T. Function of the nervous system during prenatal life. In: Uwe 13. Chamberlain PF, et al. Ultrasound evaluation of amniotic fluid volume. I.
Stave, ed. Perinatal Physiology. Springer US; 1978:651-652. The relationship of marginal and decreased amniotic fluid volumes to
6. Manning FA. Fetal biophysical profile: a critical appraisal. Clin Obstet Gynecol. perinatal outcomes. Am J Obstet Gynecol. 1984;150(3):245-249.
2002;45(4):975-985. 14. Manning FA. Fetal Assessment: Principles and Practices. Norwalk, CT: Appleton
7. Vintzileos AM, et al. The relationships among the fetal biophysical profile, and Lange; 1995.
umbilical cord pH, and Apgar scores. Am J Obstet Gynecol. 1987;157(3):
627-631.