Management of Term Pregnancy with Non-Reactive NST but Reassuring BPP
Proceed with delivery at 38.5 weeks gestation given the combination of decreased fetal movement, non-reactive NST, and active labor, despite the reassuring BPP of 8/8. 1
Rationale for Delivery
At term gestation (38.5 weeks), abnormal antenatal test results are an indication for delivery. 1 The ACR Appropriateness Criteria specifically state that a modified BPP with non-reactive NST warrants delivery in term pregnancies. 1
Key Clinical Factors Supporting Delivery:
- Term gestation status: At 38.5 weeks, the fetus is term and delivery carries minimal neonatal risk 1
- Active labor: The patient is already 4cm dilated with contractions, making expectant management impractical 1
- Decreased fetal movement: This concerning symptom prompted the evaluation and represents a potential warning sign of fetal compromise 2, 3
- Non-reactive NST: While the BPP is reassuring at 8/8, the non-reactive NST indicates the fetus is not demonstrating normal heart rate accelerations 1, 2
Critical Limitations of the Reassuring BPP
A normal BPP score does not eliminate the risk of acute fetal compromise, particularly when other concerning features are present. 4, 5
Important Caveats:
- Case reports document fetal demise despite reassuring BPP and NST: Multiple published cases show unexpected fetal death or severe compromise (including massive intracranial hemorrhage) occurring despite BPP scores of 8/8 4, 5
- No test predicts acute events: Antenatal testing cannot predict stillbirth from acute changes such as placental abruption or cord accidents 1, 2
- The non-reactive NST carries independent significance: The discordance between a non-reactive NST and normal BPP components should raise concern rather than provide false reassurance 4
Recommended Delivery Approach
Induction of labor is reasonable if there are no other contraindications, but Cesarean delivery may be warranted due to concerns about fetal well-being and potential intolerance of labor. 1
Management Algorithm:
- Continuous electronic fetal monitoring should be initiated immediately given the non-reactive NST and decreased fetal movement 1, 2
- Consider expedited delivery if any additional concerning features develop during labor monitoring 1
- Lower threshold for Cesarean delivery given the combination of non-reactive NST and decreased fetal movement, even with reassuring BPP 1
Why Not Continue Expectant Management
Although the BPP predicts fetal well-being over the next week with high negative predictive value, this patient is already at term and in active labor. 1 Continuing pregnancy beyond term with a non-reactive NST and decreased fetal movement adds unnecessary risk when delivery is already indicated. 1
The standard practice of weekly or twice-weekly testing in high-risk pregnancies becomes irrelevant when the patient is term, symptomatic, and in labor. 1, 2