The fetal biophysical profile
- Frank A Manning, MD
Frank A Manning, MD
- Clinical Professor of Obstetrics and Gynecology
- Albert Einstein College of Medicine
- Section Editors
- Charles J Lockwood, MD, MHCM
Charles J Lockwood, MD, MHCM
- Section Editor — Obstetrics
- Senior Vice President, USF Health
- Dean, Morsani College of Medicine
- Professor, Obstetrics and Gynecology
- University of South Florida
- Deborah Levine, MD
Deborah Levine, MD
- Section Editor — Imaging
- Professor of Radiology
- Director of Ob/Gyn Ultrasound
- Department of Radiology
- Beth Israel Deaconess Medical Center
The fetal biophysical profile (BPP) is a noninvasive, easily learned and performed procedure for evaluating the fetus for signs of compromise. Ultrasound is used to assess four discrete biophysical parameters: fetal movement, fetal tone, fetal breathing, and amniotic fluid volume. A separate nonstress test of the fetal heart rate can also be performed. Each of the four ultrasound parameters and the nonstress test are given a score of 0 or 2 points (no 1 point), depending upon whether specific criteria are met (table 1). A total score ≥8 implies absence of significant central nervous system hypoxemia/acidemia at the time of testing. A score ≤4 can be a sign of fetal compromise. Ideally, identification of a compromised fetus will enable the provider to perform interventions that prevent adverse fetal sequelae.
This topic will review issues related to the BPP. An overview of antenatal fetal surveillance and information on the nonstress test and the contraction stress test are available separately. (See "Overview of antepartum fetal surveillance" and "Nonstress test and contraction stress test".)
The American College of Obstetricians and Gynecologists recommends antepartum fetal surveillance with tests such as the BPP for pregnancies at increased risk of antepartum fetal demise . Specific indications for antenatal fetal assessment are discussed separately. (See "Overview of antepartum fetal surveillance", section on 'Indications for fetal surveillance'.)
Although the BPP is typically used for antepartum fetal assessment, it can also be performed intrapartum; however, its clinical utility in the intrapartum setting is unclear [2,3].
PHYSIOLOGIC BASIS OF BIOPHYSICAL MONITORING
All biophysical activities are regulated and controlled by discrete centers in the brain that are sensitive to both local factors and feedback from peripheral sensors. The presence of normal biophysical activity is presumptive evidence that these regulatory centers are intact, while the loss of normal biophysical activity can be a sign of pathologic neuronal suppression from hypoxemia, acidemia, and ischemia. However, the absence or diminution of a given biophysical activity is not always pathologic. Normal suppression of a regulatory center can occur from intrinsic fetal rhythms, such as the deep stage of quiet sleep, or from transplacental passage of drugs that cause general suppression of the brain, such as sedatives and opiates.
- Practice bulletin no. 145: antepartum fetal surveillance. Obstet Gynecol 2014; 124:182.
- Kim SY, Khandelwal M, Gaughan JP, et al. Is the intrapartum biophysical profile useful? Obstet Gynecol 2003; 102:471.
- Sassoon DA, Castro LC, Davis JL, et al. The biophysical profile in labor. Obstet Gynecol 1990; 76:360.
- Harman CR, Menticoglou S, Manning FA. Fetal oxygen uptake: A test of placental reserve. Proc Soc Obstet Gynecol Canada 1993.
- Cohn HE, Sacks EJ, Heymann MA, Rudolph AM. Cardiovascular responses to hypoxemia and acidemia in fetal lambs. Am J Obstet Gynecol 1974; 120:817.
- Nicolaides KH, Peters MT, Vyas S, et al. Relation of rate of urine production to oxygen tension in small-for-gestational-age fetuses. Am J Obstet Gynecol 1990; 162:387.
- Sherer DM, Dayal AK, Schwartz BM, et al. Acute oligohydramnios and deteriorating fetal biophysical profile associated with severe preeclampsia. J Matern Fetal Med 1999; 8:193.
- Manning FA, Platt LD, Sipos L. Antepartum fetal evaluation: development of a fetal biophysical profile. Am J Obstet Gynecol 1980; 136:787.
- Manning FA, Baskett TF, Morrison I, Lange I. Fetal biophysical profile scoring: a prospective study in 1,184 high-risk patients. Am J Obstet Gynecol 1981; 140:289.
- Pillai M, James D. Behavioural states in normal mature human fetuses. Arch Dis Child 1990; 65:39.
- Simpson L, Khati NJ, Deshmukh SP, et al. ACR Appropriateness Criteria Assessment of Fetal Well-Being. J Am Coll Radiol 2016; 13:1483.
- Patrick JE, Dalton KJ, Dawes GS. Breathing patterns before death in fetal lambs. Am J Obstet Gynecol 1976; 125:73.
- Manning FA, Martin CB Jr, Murata Y, et al. Breathing movements before death in the primate fetus (Macaca mulatta). Am J Obstet Gynecol 1979; 135:71.
- Romero R, Chervenak FA, Berkowitz RL, Hobbins JC. Intrauterine fetal tachypnea. Am J Obstet Gynecol 1982; 144:356.
- Manning FA, Morrison I, Lange IR, et al. Fetal biophysical profile scoring: selective use of the nonstress test. Am J Obstet Gynecol 1987; 156:709.
- Nageotte MP, Towers CV, Asrat T, Freeman RK. Perinatal outcome with the modified biophysical profile. Am J Obstet Gynecol 1994; 170:1672.
- Miller DA, Rabello YA, Paul RH. The modified biophysical profile: antepartum testing in the 1990s. Am J Obstet Gynecol 1996; 174:812.
- Manning FA, Morrison I, Harman CR, et al. Fetal assessment based on fetal biophysical profile scoring: experience in 19,221 referred high-risk pregnancies. II. An analysis of false-negative fetal deaths. Am J Obstet Gynecol 1987; 157:880.
- Verdurmen KM, Renckens J, van Laar JO, Oei SG. The influence of corticosteroids on fetal heart rate variability: a systematic review of the literature. Obstet Gynecol Surv 2013; 68:811.
- Subtil D, Tiberghien P, Devos P, et al. Immediate and delayed effects of antenatal corticosteroids on fetal heart rate: a randomized trial that compares betamethasone acetate and phosphate, betamethasone phosphate, and dexamethasone. Am J Obstet Gynecol 2003; 188:524.
- Mulder EJ, Derks JB, Visser GH. Antenatal corticosteroid therapy and fetal behaviour: a randomised study of the effects of betamethasone and dexamethasone. Br J Obstet Gynaecol 1997; 104:1239.
- Senat MV, Minoui S, Multon O, et al. Effect of dexamethasone and betamethasone on fetal heart rate variability in preterm labour: a randomised study. Br J Obstet Gynaecol 1998; 105:749.
- Rotmensch S, Liberati M, Vishne TH, 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; 78:493.
- Rotmensch S, Lev S, Kovo M, et al. Effect of betamethasone administration on fetal heart rate tracing: a blinded longitudinal study. Fetal Diagn Ther 2005; 20:371.
- Kelly MK, Schneider EP, Petrikovsky BM, Lesser ML. Effect of antenatal steroid administration on the fetal biophysical profile. J Clin Ultrasound 2000; 28:224.
- Rotmensch S, Liberati M, Celentano C, et al. The effect of betamethasone on fetal biophysical activities and Doppler velocimetry of umbilical and middle cerebral arteries. Acta Obstet Gynecol Scand 1999; 78:768.
- Katz M, Meizner I, Holcberg G, et al. Reduction or cessation of fetal movements after administration of steroids for enhancement of lung maturation. I. Clinical evaluation. Isr J Med Sci 1988; 24:5.
- Karaer C, Onderoglu L, Yigit N, et al. The effect of steroids on the biophysical profile and Doppler indices of umbilical and middle cerebral arteries in healthy preterm fetuses. Eur J Obstet Gynecol Reprod Biol 2001; 99:72.
- Derks JB, Giussani DA, Jenkins SL, et al. A comparative study of cardiovascular, endocrine and behavioural effects of betamethasone and dexamethasone administration to fetal sheep. J Physiol 1997; 499 ( Pt 1):217.
- Vintzileos AM. Antepartum surveillance in preterm rupture of membranes. J Perinat Med 1996; 24:319.
- Lewis DF, Adair CD, Weeks JW, et al. A randomized clinical trial of daily nonstress testing versus biophysical profile in the management of preterm premature rupture of membranes. Am J Obstet Gynecol 1999; 181:1495.
- Ghidini A, Salafia CM, Kirn V, et al. Biophysical profile in predicting acute ascending infection in preterm rupture of membranes before 32 weeks. Obstet Gynecol 2000; 96:201.
- Del Valle GO, Joffe GM, Izquierdo LA, et al. The biophysical profile and the nonstress test: poor predictors of chorioamnionitis and fetal infection in prolonged preterm premature rupture of membranes. Obstet Gynecol 1992; 80:106.
- Gauthier DW, Meyer WJ, Bieniarz A. Biophysical profile as a predictor of amniotic fluid culture results. Obstet Gynecol 1992; 80:102.
- Honest H, Bachmann LM, Sengupta R, et al. Accuracy of absence of fetal breathing movements in predicting preterm birth: a systematic review. Ultrasound Obstet Gynecol 2004; 24:94.
- Tug N, Ayvaci H, Tarhan N, et al. Effects of short-term maternal fasting in the third trimester of pregnancy on fetal biophysical profile and Doppler indices scores. Arch Gynecol Obstet 2011; 283:461.
- Nomura RM, Gordon MC, Fatobene G, et al. [Effects of maternal anemia on computerized cardiotocography and fetal biophysical profile]. Rev Bras Ginecol Obstet 2009; 31:615.
- 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; 113:687.
- Lalor JG, Fawole B, Alfirevic Z, Devane D. Biophysical profile for fetal assessment in high risk pregnancies. Cochrane Database Syst Rev 2008; :CD000038.
- Gribbin C, James D. Assessing fetal health. Best Pract Res Clin Obstet Gynaecol 2004; 18:411.
- Nageotte MP, Towers CV, Asrat T, et al. The value of a negative antepartum test: contraction stress test and modified biophysical profile. Obstet Gynecol 1994; 84:231.
- Manning FA. Fetal biophysical profile: a critical appraisal. Clin Obstet Gynecol 2002; 45:975.
- Manning FA, Morrison I, Lange IR, 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; 151:343.
- Manning FA. Fetal biophysical profile. Obstet Gynecol Clin North Am 1999; 26:557.
- Vintzileos AM, Fleming AD, Scorza WE, et al. Relationship between fetal biophysical activities and umbilical cord blood gas values. Am J Obstet Gynecol 1991; 165:707.
- Manning FA, Bondaji N, Harman CR, et al. Fetal assessment based on fetal biophysical profile scoring. VIII. The incidence of cerebral palsy in tested and untested perinates. Am J Obstet Gynecol 1998; 178:696.
- Manning FA, Snijders R, Harman CR, et al. Fetal biophysical profile score. VI. Correlation with antepartum umbilical venous fetal pH. Am J Obstet Gynecol 1993; 169:755.
- Ribbert LS, Snijders RJ, Nicolaides KH, Visser GH. Relationship of fetal biophysical profile and blood gas values at cordocentesis in severely growth-retarded fetuses. Am J Obstet Gynecol 1990; 163:569.
- Chamberlain PF, Manning FA, Morrison I, et al. Ultrasound evaluation of amniotic fluid volume. I. The relationship of marginal and decreased amniotic fluid volumes to perinatal outcome. Am J Obstet Gynecol 1984; 150:245.
- Phelan JP, Ahn MO, Smith CV, et al. Amniotic fluid index measurements during pregnancy. J Reprod Med 1987; 32:601.
- Manning FA. Dynamic ultrasound-based fetal assessment: the fetal biophysical profile score. Clin Obstet Gynecol 1995; 38:26.
- Kaur S, Picconi JL, Chadha R, et al. Biophysical profile in the treatment of intrauterine growth-restricted fetuses who weigh <1000 g. Am J Obstet Gynecol 2008; 199:264.e1.
- PHYSIOLOGIC BASIS OF BIOPHYSICAL MONITORING
- Fetal movement, tone, breathing, and heart rate acceleration
- Amniotic fluid volume
- DETERMINING THE BIOPHYSICAL PROFILE SCORE
- Can the nonstress test be omitted?
- Modified biophysical profile
- Factors potentially affecting test results
- EVIDENCE OF EFFICACY
- INITIATION AND FREQUENCY OF TESTING
- ROUTE OF DELIVERY AFTER A LOW BPP SCORE
- SUMMARY AND RECOMMENDATIONS