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Role of non stress test in monitoring antenatal fetal well being in high risk pregnancy

Background: Antepartum evaluation of the fetus at risk for damage or death in utero remains a major challenge in modern obstetrics. Freeman & Lee (1975) 1 and colleagues introduced the non-stress test to describe acceleration of fetal heart rate is a sign of fetal health in response to fetal movement. Aims: Role of Non stress test in antepartum fetal surveillance and perinatal outcome in high risk pregnancy. To prove the efficacy of NST as an effective tool for evaluation of fetal well-being. To decrease perinatal morbidity and mortality. Materials and Methods: Hospital based prospective study. 50 pregnant women with high risk factors as study group and 50 healthy pregnant women as control group were randomly selected from period of July 2015 to December 2015 in the department of Obst & Gynae Dr. S. N. Medical college Jodhpur. Non stress test performed and results were analysed. Results: Non stress test as screening test for antenatal fetal surveillance has high specificity and high negative predictive value. Conclusion: The ideal test for fetal reserve should be safe, inexpensive, readily available, quickly exerted and devoid of either false positive or false negative results. As yet no such test exists which is perfect, still NST has been shown to be most acceptable modality for evaluating the fetus in utero. © 2020 Published by Innovative Publication. This is an open access article under the CC BY-NC license (https://creativecommons.org/licenses/by-nc/4.0/)


Introduction
A high risk pregnancy is one in which some conditions put the mother, the developing fetus, or both at higher than normal risk for complications during or after the pregnancy and birth. Antepartum evaluation of the fetus at risk for damage or death in utero remains a major challenge in modern obstetrics.
According to American College of Obstetrician and Gynaecologists and American Academy of Pediatrics (2012) 2 the objectives of antepartum fetal surveillance are to prevent fetal death and avoidance of unnecessary intervention. 1 The test is named "non-stress" because no stress is placed on the fetus during test. Among all available tests this is simple to be done, can be repeated, non-harmful, cost

Materials and Methods
The present prospective study was conducted in department of Obstetrics & Gynaecology, Umaid hospital, Jodhpur from period of July 2015 to December 2015. The study was done on 100 cases. 50 high risk pregnancies were taken randomly as study group and 50 normal pregnancy cases were taken randomly as control group. The subjects were explained the test, need of the test, done after 28 weeks of gestation.

Inclusion criteria
Pregnancy complicated by Hypertensive disorders -Pre-eclampsia and chronic hypertension, Diabetes complicating pregnancy, including gestational diabetes (GDM), Intra-uterine growth retardation (IUGR), Post dated pregnancy, Liquor abnormalities, Recurrent pregnancy losses (RPL), Pregnancy with previous cesarean section, Multiple gestation, Pregnancy with medical illness, Loss or decreased fetal movements, Rh isoimmunization and Anemia.

Method
Testing protocol for NST

Observations and Results
Study (high risk) and Control (healthy) group each had 50 cases.  PIH, GDM and oligohydramnios with IUGR are commonest. Most of the patients belong to 23-26 years age group as this is peak reproductive age group.
Majority of patients are primi gravid. In study group, 3 patients had reassuring NST with abnormal perinatal outcome and diagnosis was severe pre eclampsia, previous cesarean with decreased fetal movement and previous cesarean with severe oligo with severe IUGR.
Perinatal mortality and morbidity not shown in any of the patient in control group.
In study group 82% had Reassuring NST out of which 4.87% had perinatal morbidity while 2.44% had perinatal mortality. In study group 18% had non-reassuring NST out of which 22.2% had perinatal morbidity while 11.1% had perinatal mortality. 9 patients in study group had ominous NST pattern and 5 (55.5%) out of 9 had fetal hypoxia, 2 (22.2%) had decreased fetal movements, 1 (11.1%) had loss of fetal movement and uteroplacental insufficiency.
In control group 7 new born had Apgar score of 10, 39 had score of 9 and 4 had score of 8. None in control group had low (<7) Apgar score. While in study group 3 new born had score of 10, 32 had score of 9, 9 had score of 8 and 6 had low apgar score.

Discussion
During the past decades remarkably intimate knowledge of human fetus along with technological developments have prompted a new phenomenon in medicine of forecasting fetal health.
In present study focus is on contemporary testing procedures that depend on fetal heart rate.
In this decade characteristics of fetal heart rate testing has been used increasingly to predict the condition of fetus during antenatal period.

Summary
The present study highlighted the following points: 1. 21 (42%) patients in study group were of 23-26 years age group i.e. period of maximum reproductive capacity.          2. 30 (60%) patients in high risk group were primigravida and most common (34%) high risk factor was hypertensive disorder in pregnancy followed by oligohydramnios (28%). 3. Non-reassuring NST was common (23 8% among 23-26 years age group and primigravida patients (23 3%). 4. Cesarean deliveries were common (18% among high risk group than control group (0%). 5. Perinatal morbidity and mortality was common (12%) among high risk group compared to study group (0%). 6. The sensitivity for perinatal morbidity and mortality was 50% i.e. NST detected 50% of all abnormal outcome. 7. The non-reassuring NST may be due to sleeping state, sedative drugs to mother, prematurity, chronic hypoxia or major congenital anomalies so before getting NST to be non-reassuring one should extend the duration of NST for another 20 min and should not hurry to intervene pregnancy rather should keep in mind the possible causes of non reactivity and manage accordingly. 8. Non stress test is easy to perform, informative, non invasive, reproducible, inexpensive, having no contraindication (if doubt can be repeated) but require proper logical interpretation for reliable prediction of outcome. 9. Antepartum fetal surveillance gave more reassurance to the obstetrician and decreased the number of hospital admission as well as the duration of hospital stays of many mothers. 10. None of new born in control group had low (<7) Apgar score while it was seen in 6 new born babies in study group. So fetal compromise is common in high risk pregnancy.

Conclusion
The ideal test for fetal reserve should be safe, inexpensive, readily available, quickly exerted and devoid of either false positive or false negative results. As yet no such test exists which is perfect, still NST has been shown to be most acceptable modality for evaluating the fetus in utero. Until a perfect method is devised, the importance of judicious use and meticulous interpretation of NST (CTG) will continue to dominate the science of fetal surveillance. The charm of NST is