At what gestational age should a non‑stress test be ordered for high‑risk pregnancies?

Non-Stress Testing in High-Risk Pregnancies

Non-stress testing (NST) should be initiated at 32 weeks gestation for most high-risk pregnancies, though specific maternal or fetal conditions may warrant earlier or more frequent testing. 1

Standard Timing for NST Initiation

Begin routine NST at 32–34 weeks gestation for the majority of high-risk conditions including:

• Suspected intrauterine growth restriction (IUGR)
• Pregnancy-induced hypertension
• Fetal anomalies
• Growth abnormalities
• Abnormal amniotic fluid volumes (oligohydramnios or polyhydramnios)
• Monochorionic twin pregnancies
• Multiple gestations with discordant growth 1

The 32-week threshold represents the gestational age when fetal autonomic nervous system maturation allows reliable interpretation of heart rate patterns, and when intervention for fetal compromise becomes viable with acceptable neonatal outcomes. 2, 3

Earlier Initiation (28–32 weeks)

Start NST at 28 weeks in pregnancies with:

• Preexisting diabetes (type 1 or type 2) requiring insulin treatment 4
• History of prior stillbirth
• Severe maternal medical conditions (e.g., chronic hypertension with end-organ damage, severe renal disease)
• Monoamniotic twins 1

Testing Frequency

• Once weekly is the most common practice for stable high-risk conditions 4
• Twice weekly for:
  • Insulin-requiring diabetes from 32 weeks onward 4
  • Severe IUGR with abnormal Doppler findings 1
  • Oligohydramnios
  • Post-term pregnancy (≥41 weeks)
  • Prior unexplained stillbirth 3, 5

Integration with Other Surveillance

NST should be combined with:

• Biophysical profile (BPP) when NST is nonreactive or in cases of IUGR/oligohydramnios 1
• Umbilical artery Doppler velocimetry for suspected IUGR, monochorionic twins, or growth discordance—abnormal Doppler findings (absent or reversed end-diastolic flow) are more predictive of adverse outcomes than NST alone and may be detected as early as 16–20 weeks 1
• Serial growth ultrasounds every 2–4 weeks in multiple gestations or suspected growth restriction 1

Critical Pitfalls to Avoid

Do not delay NST initiation beyond 34 weeks in recognized high-risk pregnancies—perinatal deaths from presumed asphyxia have occurred even after reactive NSTs when testing was started late or performed infrequently. 3, 5

A reactive NST predicts fetal well-being for only one week, so testing intervals must not exceed 7 days in high-risk conditions; twice-weekly testing is safer when risk is elevated. 6, 5

Nonreactive NST requires immediate further evaluation with either contraction stress test (CST) or BPP—do not simply repeat NST and discharge the patient, as nonreactive tests are associated with significantly higher rates of cesarean section for fetal distress and perinatal mortality. 3, 5

NST is more specific than sensitive—a reactive test reliably indicates fetal health, but a nonreactive test does not definitively indicate fetal compromise and must be followed by additional testing before intervention. 2, 6

Special Populations

Gestational diabetes managed with diet alone does not routinely require NST unless other high-risk factors (macrosomia, polyhydramnios, poor glycemic control) develop; however, many centers initiate weekly NST at 36–38 weeks even in diet-controlled cases. 4

Opioid use disorder (OUD) with ongoing illicit substance use may warrant NST initiation, though data supporting routine testing are limited—individualize based on presence of IUGR, oligohydramnios, or other obstetric complications rather than substance use alone. 1

Multiple gestations: NST is as reliable in twins as in singletons when standard obstetric indications are present (abnormal fluid, hypertension, growth abnormalities), and should follow the same gestational age guidelines as singleton pregnancies. 1