Evaluation of the fetal assessment score in pregnancies at risk for intrauterine hypoxia

Correlation of hematocrit and Apgar scores in newborns of women with hypertensive disorders in pregnancy

OBJECTIVES

To compare the incidence of polycythemia in newborns of women with hypertensive disorders in pregnancy (HDP) with those of normotensive mothers, to determine the incidence of perinatal stress using Apgar scores and to correlate hematocrit with Apgar scores in these newborn.

STUDY DESIGN

This was a hospital-based comparative study conducted in the University of Port Harcourt Teaching Hospital, Nigeria.

MAIN OUTCOME MEASURES

Apgar scores of 200 newborns- 100 from mothers with HDP (case group) and 100 from normotensive mothers (control group)- were taken at 1st and 5th minute of birth and cord blood samples collected to determine hematocrit. The subjects were categorized into polycythemic and non polycythemic using a hematocrit ≥65%.

RESULTS

Eight percent of newborns of women with HDP had polycythemia while none of the controls did. Apgar scores in the case group with and without polycythemia at one-minute were 4.1±1.8 and 6.6±2.1, respectively and at 5 minutes were 6.9±1.7 and 8.5±1.4 respectively. Hematocrit correlated positively with Apgar scores (both at one and five minutes) in cases without polycythemia (r = 0.221, p = 0.034 and r = 0.255, p = 0.014). Hematocrit of polycythemic newborns did not correlate with Apgar scores (r = -0.287, p = 0.491 and r = -0.436, p = 0.281).

CONCLUSION

The incidence of polycythemia is significantly higher in newborns of women with HDP and these polycythemic neonates had a significantly higher incidence of birth asphyxia. Therefore, birth outcome as determined by Apgar score is influenced by hematocrit.

The sequence of changes in Doppler and biophysical parameters as severe fetal growth restriction worsens

OBJECTIVE

To test the hypothesis that hemodynamic changes depicted by Doppler precede deteriorating biophysical profile score in severe intrauterine growth restriction.

METHODS

Intrauterine growth-restricted fetuses with elevated umbilical artery Doppler pulsatility index (PI) > 2 standard deviations above mean for gestational age and birth weight < 10th centile for gestational age were examined longitudinally. Fetal well-being was assessed serially with five-component biophysical profile scoring (tone, movement, breathing, amniotic fluid volume and non-stress test) and concurrent Doppler examination of the umbilical artery, middle cerebral artery and ductus venosus, inferior vena cava and free umbilical vein. For fetuses with a final biophysical profile score < 6/10, progression of biophysical profile scoring, arterial PI and venous peak velocity indices were analyzed longitudinally. Gestational age effect was removed by converting indices to Z-scores (deviation from gestational age mean, in standard deviations).

RESULTS

Forty-four of 236 intrauterine growth-restricted fetuses (18.6%) required delivery for abnormal biophysical profile scoring. The median gestational age at entry was 25 weeks and 1 day and at delivery was 29 weeks and 6 days. The median interval between examinations was 1.5 days and the majority had daily testing in the week prior to delivery. Between first examination and delivery, significant deterioration was observed for Doppler criteria (chi-square, P < 0.001) and biophysical parameters (Fisher's exact, P = 0.02) predominantly confined to the week prior to delivery/stillbirth. Doppler variables changed first. In 42 fetuses (95.5%), one or more vascular beds deteriorated, accelerating especially in the umbilical artery and ductus venosus at a median of 4 days before biophysical profile scoring deteriorated. Two to 3 days before delivery, fetal breathing movement began to decline. The next day, amniotic fluid volume began to drop. Composite biophysical profile score dropped abruptly on the day of delivery, with loss of fetal movement and tone. Three principal patterns of Doppler deterioration were observed: (i) worsening umbilical artery PI, advent of brain sparing and venous deterioration (n = 32, 72.7%); (ii) abnormal precordial venous flows, advent of brain sparing (n = 6, 13.6%); and (iii) abnormal ductus venosus only (n = 4, 9.1%). In the majority (31, 70.5%), Doppler deterioration was complete 24 h before biophysical profile score decline. In the remainder (11, 25%), Doppler deterioration and biophysical profile score < 6/10 were simultaneous.

CONCLUSION

In the majority of severely intrauterine growth-restricted fetuses, sequential deterioration of arterial and venous flows precedes biophysical profile score deterioration. Adding serial Doppler evaluation of the umbilical artery, middle cerebral artery and ductus venosus to intrauterine growth restriction surveillance will enhance the performance of the biophysical score in the detection of fetal compromise and therefore optimizing the timing of intervention.

Evaluation of an adapted model of the World Health Organization partograph used by Angolan midwives in a peripheral delivery unit

OBJECTIVE

To study the impact of an educational intervention of midwives' use of the Angolan model of the World Health Organization's (WHO) partograph.

SETTING

A peripheral delivery unit with approximately 1500 deliveries per year, run by eleven midwives in Luanda, Angola.

DESIGN

The quasi-experimental, One-Group Pre-test-Post-test design was used in this study. Fifty partographs plotted with an initial dilatation < 8 cm were randomly selected from the first period of six month to form sample I, and another fifty from the second six-months period to form sample II.

INTERVENTION

In-service education (theory and practice) performed by a team of midwives and an obstetrician.

MEASUREMENTS AND FINDINGS

When comparing sample II with sample I, statistically significant improvements were found in seven of 10 measured variables. This indicates a positive effect of the educational intervention on a proper use of the partograph. Due to the small sample size, however, this study cannot evaluate action taken in relation to prolonged labour.

IMPLICATIONS FOR PRACTICE

The in-service educational programme may be of use when introducing the WHO partograph in similar settings, and the findings of this study may indicate which parts of the programme need more emphasis.

CONCLUSIONS

The midwives improved in general their documentation of the partograph. However, they tended to exceed established criteria for responsibilities at the peripheral delivery unit, a fact supported by an increased number of missed transfers. The study did not, however, answer the question why the midwives acted as they did in the referred cases.

Comparison of the modified biophysical profile to a "new" biophysical profile incorporating the middle cerebral artery to umbilical artery velocity flow systolic/diastolic ratio

OBJECTIVES

The objective of this study was to determine whether the addition of the middle cerebral to umbilical artery systolic/diastolic velocity waveform ratio to the modified biophysical profile would improve perinatal outcome in patients at high risk.

STUDY DESIGN

A prospective, randomized outcome study of patients referred to the perinatal laboratory for antenatal surveillance was undertaken. Six hundred sixty-five patients were randomized to two antenatal surveillance protocols: group 1, modified biophysical profile; and group 2, modified biophysical profile plus evaluation of the middle cerebral artery to umbilical artery systolic/diastolic ratio. Patients were followed up serially and neonatal outcome data including gestational age at delivery, birth weight, incidence of cesarean section delivery for fetal distress, admission to the neonatal intensive care unit, days in the neonatal intensive care unit, and the presence of significant neonatal morbidity were tabulated.

RESULTS

The total population showed no statistical difference in outcome parameters between groups 1 and 2. However, a subgroup of patients evaluated for suspected uteroplacental insufficiency did show a significant reduction in caesarean section for fetal distress in group 2 patients.

CONCLUSIONS

In a subgroup of patients at risk for uteroplacental insufficiency, the addition of the middle cerebral/umbilical artery ratio to an antenatal surveillance protocol should be expected to improve perinatal outcome.