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Biophysical Profile Score (BPS or BPP)

The biophysical profile is a test used to evaluate the well-being of the fetus.  The biophysical profile uses ultrasound and cardiotocography (CTG) , also known as  electronic fetal heart rate monitoring , to examine the fetus. There are five components measured during the biophysical examination. A score of 2 points is given for each component that meets criteria as listed in the table below. The test is continued until all criteria are met or 30 minutes have elapsed. The points are then added for a possible maximum score of 10.
 
Component  Normal (2 points) Abnormal (0 points)
Fetal Breathing Movements One or more episodes of fetal breathing lasting at least 30 seconds within 30 minutes. No episodes of fetal breathing movements lasting at least 30 seconds during a 30 minute period of observation.
Gross Body Movement 3 or more discrete body or limb movements within 30 minutes Less than 3 body or limb movements in 30 minutes
Fetal Tone One or more episodes of active extension and flexion of a fetal extremity OR opening and closing of the hand within 30 minutes Slow extension with no return or slow return to flexion of a fetal extremity  OR no  fetal movement
Amniotic Fluid Volume * A single deepest vertical pocket of amniotic fluid measures greater than 2 centimeters. is present A single deepest vertical pocket of amniotic fluid measures 2 centimeters or less
Non-stress test (NST)** Reactive Nonreactive

*Amniotic Fluid Volume Measured as the vertical measurement , in centimeters, of the single deepest pocket of amniotic fluid with a transverse measurement of 1 cm or more wide  without fetal small parts or umbilical cord . [2] 
** Reactive Two or more fetal heart rate accelerations that peak (but do not necessarily remain) at least 15 beats per minute above the baseline and last at least 15 seconds from baseline to baseline during 20 minutes of observation
**Nonreactive Less than two accelerations of fetal heart rate as described above after 40 minutes of observation [1] 


Biophysical Profile Test Score Results

A total  score of 10 out of 10  or 8 out of 10 with normal fluid is considered normal. A score of 6 is considered equivocal, and a score of 4 or less is abnormal   [1,3, 6]. A score of less than 8 indicates the fetus may not be receiving enough oxygen. However, decreased  biophysical activities may also be seen for a brief time  in the preterm fetus after treatment with ether betamethasone or dexamethasone given to enhance fetal lung maturity [7]. The likelihood that the fetus is  not getting enough oxygen and the risk for fetal death  increase as the BPP score decreases.

Test Score

Management

ACOG [6] SOGC [1]
10 out of 10  ,  8 out of 10 (normal fluid), 8 out of 10 (NST not done)   Deliver for obstetric or maternal factors
8 out of 10
(abnormal fluid)
Uncomplicated, isolated persistent oligohydramnios deliver at 36 to 37 weeks . If there is normal urinary tract function  and intact membranes then deliver at term. If < 34 weeks intensive surveillance to maximize maturity
6 out of 10 (normal fluid) At or beyond 37 0/7 weeks of gestation,  further evaluation and consideration of delivery. Less than 37 0/7 weeks  repeat BPP in 24 hours Repeat test within 24 hours
6 out of 10
(abnormal fluid)
Deliver if at term .If < 34 weeks intensive surveillance to maximize maturity
4 out of 10 Delivery is usually indicated. Pregnancies at less than 32 0/7 weeks of gestation, management should be individualized, and extended monitoring may be appropriate. Deliver
2 out of 10 Deliver Deliver
0 out of 10 Deliver Deliver


The Modified Biophysical Profile (MBPP)

Some testing centers use a modified biophysical profile [4,5]. The modified BPP consists of the nonstress test (NST) and an amniotic fluid volume assessment. The modified BPP is considered normal if the NST is reactive and the deepest vertical pocket of amniotic fluid is  greater than 2 centimeters. The modified BPP is considered abnormal if either the NST is nonreactive or the deepest vertical pocket of amniotic fluid is 2 cm or less [1].

When is the  MBPP or BPP Usually Performed?

The modified BPP  may be performed for decreased fetal movement.  If the NST is nonreactive or the amniotic fluid volume is low a full BPP is usually done. 

ACOG recommends the MBPP or BPP may also be used for antepartum fetal surveillance in pregnancies at increased risk for bad perinatal outcomes including , but not limited to, pregnancies complicated by hypertension, preeclampsia, pregestational diabetes, poorly controlled or medically treated gestational diabetes, poorly controlled hyperthyroidism, chronic renal disease, systemic lupus erythematosus, antiphospholipid syndrome, hemoglobinopathy (sickle cell disease) , maternal cyanotic heart disease, moderate or severe asthma during pregnancy,  isoimmunization,  oligohydramnios, unexplained or recurrent risk for stillbirth, fetal growth restriction , and late term pregnancy at or beyond 41 0/7 weeks  [1, 9,10].

The Society of Obstetricians and Gynaecologists of Canada (SOGC) suggests antenatal fetal surveillance may also be beneficial in pregnancies complicated by preterm premature rupture of membranes, chronic (stable abruption) , vaginal bleeding, abnormal maternal serum screening in the absence of confirmed fetal anomaly, motor vehicle accident during pregnancy, morbid obesity, advanced maternal age, assisted reproductive technologies , multiple pregnancy, polyhydramnios, and preterm labor [6].

In addition to many of the above indications an executive summary by a Eunice Kennedy Shriver National Institute of Child Health and Human Development workshop on antenatal testing  suggested antepartum testing for cholestasis of pregnancy was appropriate. However, the workshop found insufficient data to recommend antenatal testing for other conditions such as  obesity, advanced maternal age, abnormal maternal serum markers, thrombophilias, triplets and higher-order multiples [11].

The American College of Obstetricians and Gynecologists has observed  that despite a lack of high quality evidence that antepartum surveillance decreases the risk of fetal death ..."antepartum fetal surveillance is widely integrated into clinical practice in the developed world." [1,8]. ACOG advises "... initiating antepartum fetal testing no earlier than 32 0/7 weeks of gestation is appropriate for most at-risk patients . However, in pregnancies with multiple or particularly worrisome high-risk conditions (e.g., chronic hypertension with suspected fetal growth restriction), testing might begin at a gestational age when delivery would be considered for perinatal benefit".  If delivery is not planned (eg, given early gestational age), then antenatal surveillance should not be performed because the results will not inform management  [1].

Reviewed by Mark Curran, M.D.


REFERENCES

1. Antepartum fetal surveillance. Practice Bulletin No. 145. American College of Obstetricians and Gynecologists. Obstet Gynecol 2014;124:18292PMID:24945455
2. Chamberlain PF, Manning FA, Morrison I, Harman CR, Lange IR. Ultrasound evaluation of amniotic fluid volume. I. The relationship of marginal and decreased amniotic fluid volume to perinatal outcome. Am J Obstet Gynecol 1984;150:2459.PMID:6385713
3. Manning FA, et. al., Fetal assessment based on fetal biophysical profile scoring: experience in 12,620 referred high-risk pregnancies. I. Perinatal mortality by frequency and etiology.Am J Obstet Gynecol. 1985 Feb 1;151(3):343-50. PMID: 3881967
4. Nageotte MP, et. al. Perinatal outcome with the modified biophysical profile. Am J Obstet Gynecol. 1994 Jun;170(6):1672-6.
PMID:8203424
5.Miller DA, et. al., The modified biophysical profile: antepartum testing in the 1990s.Am J Obstet Gynecol. 1996 Mar;174(3):812-7. PMID:8633648
6. Fetal health surveillance: antepartum and intrapartum consensus guideline. Liston R, Sawchuck D, Young D; Society of Obstetrics and Gynaecologists of Canada; British Columbia Perinatal Health Program. J Obstet Gynaecol Can. 2007 Sep;29(9 Suppl 4):S3-56. Erratum in: J Obstet Gynaecol Can. 2007 Nov;29(11):909. PMID:17845745 Available at: http://sogc.org/wp-content/uploads/2013/01/gui197CPG0709r.pdf
7. Rotmensch S, et. al., The effect of betamethasone and dexamethasone on fetal heart rate patterns and biophysical activities. A prospective randomized trial.Acta Obstet Gynecol Scand. 1999 Jul;78(6):493-500. PMID: PMID:10376858
8.Lalor JG, et. al. Biophysical profile for fetal assessment in high risk pregnancies. Cochrane Database Syst Rev. 2008 Jan 23;(1):CD000038. doi: 10.1002/14651858.CD000038.pub2. PMID: PMID:18253968

9. Asthma in pregnancy. ACOG Practice Bulletin No. 90. American College of Obstetricians and Gynecologists. Obstet Gynecol 2008; 111:45764.PMID: PMID:18238988
10. Management of late-term and postterm pregnancies. Practice Bulletin No. 146. American College of Obstetricians and Gynecologists. Obstet Gynecol 2014;124:3906.PMID: PMID:25050770   
11.  Signore C, Freeman RK, Spong CY. Antenatal testing-a reevaluation: executive summary of a Eunice Kennedy Shriver National Institute of Child Health and Human Development workshop. Obstet Gynecol. 2009;113:687701 PMID: PMID:19300336
           
 

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