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Determination of Foetal Scalp Blood Sampling pH as an Indicator of Loss of Foetal Well-Being in Women Undergoing Caesarean Section. Healthcare (Basel) 2023; 11:healthcare11050725. [PMID: 36900730 PMCID: PMC10001157 DOI: 10.3390/healthcare11050725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 02/23/2023] [Accepted: 02/28/2023] [Indexed: 03/06/2023] Open
Abstract
Asphyxia during birth is one of the three leading causes of neonatal morbidity and mortality among newborns carried to term. The objective of this study was to evaluate the measurement of the foetal scalp blood pH as a measure of foetal status, evaluating: cord gases, meconium-stained fluid, APGAR score or the need for neonatal resuscitation in pregnant women undergoing caesarean sections. A cross-sectional study was carried out over a period of 5 years (2017-2021) at the Hospital de Poniente (southern Spain). A total of 127 pregnant women participated from whom a foetal scalp blood pH sample was taken and used to indicate the need for an urgent caesarean section. The results showed a correlation between the pH of the scalp blood and the pH of the umbilical cord artery, umbilical cord vein (Rho of Spearman arterial pH: 0.64, p < 0.001; Rho of Spearman venous pH: 0.58, p < 0.001) and the APGAR test one minute after delivery (Spearman's Rho coefficient of 0.33, p < 0.01). These results suggest that the foetal scalp pH should not be considered a foolproof method to indicate an urgent caesarean section. Foetal scalp pH sampling can be used as a complementary test, in conjunction with cardiotocography, to indicate whether an emergency caesarean section is necessary due to loss of foetal well-being.
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Murphy DJ, Devane D, Molloy E, Shahabuddin Y. Fetal scalp stimulation for assessing fetal well-being during labour. Cochrane Database Syst Rev 2023; 1:CD013808. [PMID: 36625680 PMCID: PMC9831024 DOI: 10.1002/14651858.cd013808.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Continuous fetal heart rate monitoring by cardiotocography (CTG) is used in labour for women with complicated pregnancies. Fetal heart rate abnormalities are common and may result in the decision to expedite delivery by caesarean section. Fetal scalp stimulation (FSS) is a second-line test of fetal well-being that may provide reassurance that the labour can continue. OBJECTIVES To evaluate methods of FSS as second-line tests of intrapartum fetal well-being in cases of non-reassuring CTG. FSS and CTG were compared to CTG alone, and to CTG with fetal blood sampling (FBS). SEARCH METHODS We searched Cochrane Pregnancy and Childbirth's Trials Register (which includes trials from CENTRAL, MEDLINE, Embase, CINAHL, the WHO ICTRP and conference proceedings), ClinicalTrials.gov (18 October 2022), and reference lists of retrieved studies. SELECTION CRITERIA Eligible studies were randomised controlled trials (RCTs) that compared any form of FSS to assess fetal well-being in labour. Quasi-RCTs, cluster-RCTs and studies published in abstract form were also eligible for inclusion, but none were identified. DATA COLLECTION AND ANALYSIS Two review authors independently assessed studies for inclusion and risk of bias, extracted data and checked them for accuracy. We assessed the certainty of the evidence using the GRADE approach. MAIN RESULTS Two trials, involving 377 women, met the inclusion criteria for this review. Both trials were conducted in hospital settings and included women with singleton, term (37+0 weeks or more) pregnancies, a cephalic presentation, and abnormal CTG. Follow-up was until hospital discharge after the birth. A pilot trial of 50 women in a high-income country (Ireland) compared CTG and digital fetal scalp stimulation (dFSS) with CTG and fetal blood sampling (FBS). A single-centre trial of 327 women in a lower middle-income country (India) compared CTG and manual fetal stimulation (abdominal or vaginal scalp stimulation) with CTG alone. The two included studies were at moderate or unclear risk of bias. Both trials provided clear information on allocation concealment but it was not possible to blind participants or health professionals in relation to the intervention. Although objective outcome measures were reported, outcome assessment was not blinded or blinding was unclear. dFSS and CTG versus FBS and CTG There were no perinatal deaths and data were not reported for neurodevelopmental disability at >/= 12 months. The risk of caesarean section (CS) may be lower with dFSS compared to FBS (risk ratio (RR) 0.38, 95% confidence interval (CI) 0.16 to 0.92; 1 pilot trial, 50 women; very low-certainty evidence) but the evidence is very uncertain. There were no cases of neonatal encephalopathy reported. The evidence was also very uncertain between dFSS and FBS for assisted vaginal birth (RR 1.44, 95% CI 0.76 to 2.75; very low-certainty evidence) and for the spontaneous vaginal birth rate (RR 2.33, 95% CI 0.68 to 8.01, very low-certainty evidence). Maternal acceptability of the procedures was not reported. FSS and CTG versus CTG alone Manual stimulation of the fetus was performed either abdominally (92/164) or vaginally (72/164). There were no perinatal deaths and data were not reported for neurodevelopmental disability at >/= 12 months. There may be little differences in the risk of CS on comparing manual fetal stimulation and CTG with CTG alone (RR 0.83, 95% CI 0.59 to 1.18; 1 trial, 327 women; very low-certainty evidence), but again the evidence was very uncertain. There were no cases of neonatal encephalopathy reported. There may be no differences in the risk of assisted vaginal birth (RR 1.43, 95% CI 0.78 to 2.60; very low-certainty evidence) or in the rates of spontaneous vaginal birth (RR 1.01, 95% CI 0.85 to 1.21, very low-certainty evidence), but again the evidence is very uncertain. Maternal acceptability of abdominal stimulation/FSS was not reported although 13 women withdrew consent after randomisation due to concerns about fetal well-being. AUTHORS' CONCLUSIONS There is very low-certainty evidence available which makes it unclear whether stimulating the fetal scalp is a safe and effective way to confirm fetal well-being in labour. Evidence was downgraded based on limitations in study design and imprecision. Further high-quality studies of adequate sample size are required to evaluate this research question. In order to be generalisable, these trials should be conducted in different settings, including broad clinical criteria at both preterm and term gestational ages, and standardising the method of stimulation. There is an ongoing study (FIRSST) that will be incorporated into this review in a subsequent update.
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Affiliation(s)
- Deirdre J Murphy
- Department of Obstetrics and Gynaecology Trinity College, University of Dublin, Dublin, Ireland
| | - Declan Devane
- School of Nursing and Midwifery, National University of Ireland Galway, Galway, Ireland
| | - Eleanor Molloy
- Department of Paediatrics, Trinity College Dublin, Dublin, Ireland
| | - Yulia Shahabuddin
- Department of Obstetrics and Gynaecology Trinity College, University of Dublin, Dublin, Ireland
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Maternal Physiological Variations Induced by Chronic Gestational Hypoxia: 1H NMR-Based Metabolomics Study. Molecules 2022; 27:molecules27228013. [PMID: 36432114 PMCID: PMC9693043 DOI: 10.3390/molecules27228013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 11/09/2022] [Accepted: 11/11/2022] [Indexed: 11/19/2022] Open
Abstract
Metabolomics have been widely used in pregnancy-related diseases. However, physiological variations induced by chronic hypoxia during pregnancy are not well characterized. We aimed to investigate physiological variations induced by chronic hypoxia during pregnancy. A Sprague-Dawley (SD) pregnant rat model of chronic hypoxia was established. Plasma and urine metabolite profiles at different stages of the pregnancy were detected by 1H NMR (nuclear magnetic resonance). Multivariate statistical analysis was used to analyze changes in plasma and urine metabolic trajectories at different time-points. We identified hypoxia-induced changes in the levels of 30 metabolites in plasma and 29 metabolites in urine during different stages of pregnancy; the prominently affected metabolites included acetic acid, acetone, choline, citric acid, glutamine, isoleucine, lysine, and serine. Most significant hypoxia-induced changes in plasma and urine sample metabolites were observed on the 11th day of gestation. In summary, chronic hypoxia has a significant effect on pregnant rats, and may cause metabolic disorders involving glucose, lipids, amino acids, and tricarboxylic acid cycle. Metabolomics study of the effect of hypoxia during pregnancy may provide insights into the pathogenesis of obstetric disorders.
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Murphy DJ, Shahabuddin Y, Yambasu S, O'Donoghue K, Devane D, Cotter A, Gaffney G, Burke LA, Molloy EJ, Boland F. Digital fetal scalp stimulation (dFSS) versus fetal blood sampling (FBS) to assess fetal wellbeing in labour-a multi-centre randomised controlled trial: Fetal Intrapartum Randomised Scalp Stimulation Trial (FIRSST NCT05306756). Trials 2022; 23:848. [PMID: 36195894 PMCID: PMC9531493 DOI: 10.1186/s13063-022-06794-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 09/26/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Cardiotocography (CTG) is a screening test used to detect fetal hypoxia in labour. It has a high false positive rate resulting in many potentially unnecessary caesarean sections. Fetal blood sampling (FBS) is a second-line test of the acid-base status of the fetus. It is used to provide either reassurance that it is safe for labour to continue or objective evidence of compromise so that delivery can be expedited. Digital fetal scalp stimulation (dFSS) to elicit a fetal heart rate acceleration is an alternative less invasive second-line test of fetal wellbeing. This study aims to provide robust evidence on the role of these two second-line tests in assessing fetal wellbeing and potentially preventing operative delivery. METHODS A multi-centre parallel group randomised controlled trial (RCT) is planned in four maternity centres in Ireland. The study aims to recruit 2500 nulliparous women with a term (≥37+0 weeks) singleton pregnancy who require a second-line test of fetal wellbeing in labour due to an abnormal CTG. Women will be allocated randomly to dFSS or FBS on a 1:1 ratio. The primary outcome is caesarean section. With 1250 women in each arm, the study will have 90% power to detect a difference of 5-6%, at a two-sided alpha significance level of 5%, assuming a caesarean section rate of at least 20% in the dFSS group. DISCUSSION If the proposed study shows evidence that dFSS is a safe, reliable and effective alternative to FBS, this would have ground-breaking implications for labour management worldwide. It could potentially lead to a reduction in invasive procedures and emergency caesarean sections. TRIAL REGISTRATION ClinicalTrials.gov NCT05306756. Registered on 31 March 2022. The trial commenced enrolment on 10 May 2022. Ethical committee approval has been granted by the Research Ethics Committee (REC) of each hospital: Dublin/CWIUH REC: 12.06.2019; Cork/UCC REC: 29.11.2019; Galway/NUIG REC: 06.09.2019; Limerick/UL REC: 30.09.2019.
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Affiliation(s)
- D J Murphy
- Academic Department of Obstetrics and Gynaecology, Coombe Women & Infants University Hospital & Trinity College, University of Dublin, Dublin, Ireland.
| | - Y Shahabuddin
- Academic Department of Obstetrics and Gynaecology, Coombe Women & Infants University Hospital & Trinity College, University of Dublin, Dublin, Ireland
| | - S Yambasu
- Academic Department of Obstetrics and Gynaecology, Coombe Women & Infants University Hospital & Trinity College, University of Dublin, Dublin, Ireland
| | - K O'Donoghue
- Pregnancy Loss Research Group, Department of Obstetrics & Gynecology, University College Cork, Cork, Ireland.,INFANT Research Centre, University College Cork, Cork, Ireland
| | - D Devane
- University of Galway, School of Nursing and Midwifery, HRB-Trials Methodology Research Network, Evidence Synthesis Ireland and Cochrane Ireland, Galway, Ireland
| | - A Cotter
- Department of Obstetrics and Gynecology, University of Limerick, Limerick, Ireland
| | - G Gaffney
- Department of Obstetrics and Gynaecology, University of Galway, Galway, Ireland
| | - L A Burke
- Department of Economics, Cork University Business School, University College Cork, Cork, Ireland
| | - E J Molloy
- Department of Paediatrics, Trinity College Dublin, Dublin, Ireland
| | - F Boland
- Data Science Centre and the Department of General Practice, RCSI, Dublin, Ireland
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The association between uterine contraction frequency and fetal scalp pH in women with suspicious or pathological fetal heart rate tracings: A retrospective study. Eur J Obstet Gynecol Reprod Biol 2022; 271:1-6. [DOI: 10.1016/j.ejogrb.2022.01.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Revised: 01/22/2022] [Accepted: 01/27/2022] [Indexed: 11/18/2022]
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Tigchelaar F, Groen H, Westgren M, Huinink KD, Cremers T, van den Berg PP. A new microdialysis probe for continuous lactate measurement during fetal monitoring: Proof of concept in an animal model. Acta Obstet Gynecol Scand 2020; 99:1411-1416. [PMID: 32274792 PMCID: PMC7540415 DOI: 10.1111/aogs.13865] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 03/28/2020] [Accepted: 03/31/2020] [Indexed: 01/11/2023]
Abstract
INTRODUCTION Cardiotocography (CTG) is currently the most commonly used method for intrapartum fetal monitoring during labor. However, a high false-positive rate of fetal acidosis indicated by CTG leads to an increase in obstetric interventions. We developed a microdialysis probe that is integrated into a fetal scalp electrode allowing continuous measurement of lactate subcutaneously, thus giving instant information about the oxygenation status of the fetus. Our aim was to establish proof of concept in an animal model using a microdialysis probe to monitor lactate subcutaneously. MATERIAL AND METHODS We performed an in vivo study in adult male wild-type Wistar rats. We modified electrodes used for CTG monitoring in human fetuses to incorporate a microdialysis membrane. Optimum flow rates for microdialysis were determined in vitro. For the in vivo experiment, a microdialysis probe was inserted into the skin on the back of the animal. De-oxygenation and acidosis were induced by lowering the inspiratory oxygen pressure. Oxygenation and heart rate were monitored. A jugular vein cannula was inserted to draw blood samples for analysis of lactate, pH, pco2 , and saturation. Lactate levels in dialysate were compared with plasma lactate levels. RESULTS Baseline blood lactate levels were around 1 mmol/L. Upon de-oxygenation, oxygen saturation fell to below 40% for 1 h and blood lactate levels increased 2.5-fold. Correlation of dialysate lactate levels with plasma lactate levels was 0.89 resulting in an R2 of .78 in the corresponding linear regression. CONCLUSIONS In this animal model, lactate levels in subcutaneous fluid collected by microdialysis closely reflected blood lactate levels upon transient de-oxygenation, indicating that our device is suitable for subcutaneous measurement of lactate. Microdialysis probe technology allows the measurement of multiple compounds in the dialysate, such as glucose, albumin, or inflammatory mediators, so this technique may offer the unique possibility to shed light on fetal physiology during the intrapartum period.
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Affiliation(s)
- Froukje Tigchelaar
- Faculty of Medical SciencesUniversity of GroningenGroningenthe Netherlands
| | - Henk Groen
- Department of EpidemiologyUniversity of GroningenUniversity Medical Center GroningenGroningenthe Netherlands
| | | | | | - Thomas Cremers
- CAN Holding B.V.Groningenthe Netherlands
- Department of Pharmaceutical AnalysisFaculty of Science and EngineeringUniversity of GroningenGroningenthe Netherlands
| | - Paul P. van den Berg
- Department of Obstetrics & GynecologyUniversity of GroningenUniversity Medical Center GroningenGroningenthe Netherlands
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Stål I, Wennerholm UB, Nordstrom L, Ladfors L, Wiberg-Itzel E. Fetal scalp blood sampling during second stage of labor - analyzing lactate or pH? A secondary analysis of a randomized controlled trial. J Matern Fetal Neonatal Med 2020; 35:1100-1107. [PMID: 32233704 DOI: 10.1080/14767058.2020.1743656] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Background: Cardiotocography (CTG) is a widely used method for assessing fetal wellbeing during labor. It is well-known that CTG has high sensitivity but low specificity. To avoid unnecessary operative interventions, adjunctive methods such as fetal blood sampling (FBS) are used. Few studies have looked into whether FBS can be used during second stage of labor, and in that case, which of the methods (lactate or pH) are preferred.Objective: To evaluate clinical effectiveness of measuring lactate versus pH in preventing birth acidemia when FBS was performed during second stage of labor.Methods: Secondary analysis of a randomized controlled trial . Thousand three hundred and thirty-eight women with a singleton pregnancy, cephalic presentation, gestational age ≥34 weeks, and indication for FBS during second stage of labor were included.Main outcome measures: Metabolic acidemia (pH <7.05 and base deficit >12 mmol/l) or pH < 7.00 in cord arterial blood at birth.Secondary outcomes: A composite outcome (metabolic acidemia, pH <7 or Apgar score <4), and rates of operative deliveries.Results: Metabolic acidemia occurred in 4.1% in the lactate versus 5.1% in the pH group (relative risk (RR): 0.80; 95% confidence interval (CI): 0.48-1.35) and pH <7 in 1.4% versus 2.8% (RR: 0.51, 95% CI: 0.23-1.13). Composite outcome was found in 3.8 versus 4.9%, respectively (RR: 0.76; 95% CI: 0.46-1.26). No difference in total operative interventions was found. More cesarean deliveries were performed in the lactate group (16.5 vs. 12.4%; RR: 1.33; 95% CI: 1.02-1.74).Conclusion: When analyzing lactate or pH in fetal scalp blood during second stage of labor neonatal outcomes were comparable. The frequency of total operative interventions was similar but more cesarean deliveries were performed in the lactate group.
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Affiliation(s)
- Ingrid Stål
- Department of Obstetrics and Gynecology, Institute of Clinical Sciences at Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital East, Gothenburg, Sweden
| | - Ulla-Britt Wennerholm
- Department of Obstetrics and Gynecology, Institute of Clinical Sciences at Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital East, Gothenburg, Sweden
| | - Lennart Nordstrom
- Department of Women and Children's Health, Karolinska Institute, Stockholm, Sweden.,Department of Pregnancy and Delivery, Karolinska University Hospital, Stockholm, Sweden
| | - Lars Ladfors
- Department of Obstetrics and Gynecology, Institute of Clinical Sciences at Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital East, Gothenburg, Sweden
| | - Eva Wiberg-Itzel
- Department of Clinical Science and Education, Section of Obstetrics and Gynecology, Karolinska Institute, Womens clinic Sodersjukhuset, Stockholm, Sweden
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Hughes O, Murphy DJ. Comparing second-line tests to assess fetal wellbeing in Labor: a feasibility study and pilot randomized controlled trial. J Matern Fetal Neonatal Med 2020; 35:91-99. [PMID: 31928269 DOI: 10.1080/14767058.2020.1712704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Objective: To explore the feasibility of conducting a randomized controlled trial (RCT) designed to compare the performance of digital fetal scalp stimulation (dFSS) and fetal blood sampling (FBS) as second-line tests of fetal wellbeing in Labor.Design: A feasibility study included 66 women who consented to both dFSS and FBS performed contemporaneously. A pilot randomized controlled trial included 50 women who were randomized to either dFSS or FBS.Setting: University-affiliated maternity hospital.Population: Women in Labor who required second-line testing of fetal well-being following abnormal fetal heart rate monitoring.Outcome measures: The primary outcome of interest was delivery by emergency cesarean section. Secondary outcomes included maternal and perinatal morbidity outcomes and procedural factors.Results: Of the 66 women recruited to the feasibility study 50 (76%) received the two interventions as per protocol. The demographic data indicated that future RCT should be limited to nulliparous women. After initial training and reminders, the dFSS procedure appeared to be acceptable to patients and clinicians and was interpreted appropriately. Recruitment of eligible women to the pilot RCT was successful (88%) with 50 of 63 eligible women randomized (79%) and no drop-outs. The cesarean section rate was high in both arms as expected with a cohort of women requiring second-line tests for abnormal fetal heart rate monitoring in Labor (5/25; 20% dFSS versus 13/25; 52% FBS, p = .018). Conservative estimates suggest that a sample size of 2500 randomized women would be required for a definitive RCT.Conclusions: This study suggests that dFSS, which has the potential to be a reliable alternative to FBS, could be evaluated in a well-designed randomized controlled trial.Trial registration: The definitive trial has been registered ISRCTN 13295826.
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Affiliation(s)
- O Hughes
- Academic Department of Obstetrics and Gynaecology, Coombe Women and Infants University Hospital and Trinity College, University of Dublin, Dublin, Ireland
| | - D J Murphy
- Academic Department of Obstetrics and Gynaecology, Coombe Women and Infants University Hospital and Trinity College, University of Dublin, Dublin, Ireland
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Al Wattar BH, Lakhiani A, Sacco A, Siddharth A, Bain A, Calvia A, Kamran A, Tiong B, Warwick B, MacMahon C, Marcus D, Long E, Coyle G, Lever GE, Michel G, Gopal G, Baig H, Price HL, Badri H, Stevenson H, Hoyte H, Malik H, Edwards J, Hartley J, Hemers J, Tamblyn J, Dalton JAW, Frost J, Subba K, Baxter K, Sivakumar K, Murphy K, Papadakis K, Bladon LR, Kasaven L, Manning L, Prior M, Ghosh M, Couch M, Altunel M, Pearce M, Cocker M, Stephanou M, Jie M, Mistry M, Wahby MO, Saidi NS, Ramshaw NL, Tempest N, Parker N, Tan PL, Johnson RL, Harris R, Tildesley R, Ram R, Painuly R, Cuffolo R, Bugeja R, Ngadze R, Grainger R, Gurung S, Mak S, Farrell S, Cowey S, Neary S, Quinn S, Nijjar SK, Kenyon S, Lamb S, Tracey S, Lee T, Kinsella T, Davidson T, Corr T, Sampson U, McQueen V, Smith WP, Castling Z. Evaluating the value of intrapartum fetal scalp blood sampling to predict adverse neonatal outcomes: A UK multicentre observational study. Eur J Obstet Gynecol Reprod Biol 2019; 240:62-67. [PMID: 31229725 DOI: 10.1016/j.ejogrb.2019.06.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 05/26/2019] [Accepted: 06/11/2019] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To evaluate the value of fetal scalp blood sampling (FBS) as an adjunct test to cardiotocography, to predict adverse neonatal outcomes. STUDY DESIGN A multicentre service evaluation observational study in forty-four maternity units in the UK. We collected data retrospectively on pregnant women with singleton pregnancy who received FBS in labour using a standardised data collection tool. The primary outcome was prediction of neonatal acidaemia diagnosed as umbilical cord arterial pH < 7.05, the secondary outcomes were the prediction of Apgar scores<7 at 1st and 5th minutes and admission to the neonatal intensive care unit (NICU). We evaluated the correlation between the last FBS blood gas before birth and the umbilical cord blood and adjusted for time intervals. We constructed 2 × 2 tables to calculate the sensitivity, specificity, positive (PPV) and negative predictive value (NPV) and generated receiver operating curves to report on the Area Under the Curve (AUC). RESULTS In total, 1422 samples were included in the analysis; pH values showed no correlation (r = 0.001, p = 0.9) in samples obtained within an hour (n = 314), or within half an hour from birth (n = 115) (r=-0.003, p = 0.9). A suboptimal FBS pH value (<7.25) had a poor sensitivity (22%) and PPV (4.9%) to predict neonatal acidaemia with high specificity (87.3%) and NPV (97.4%). Similar performance was noted to predict Apgar scores <7 at 1st (sensitivity 14.5%, specificity 87.5%, PPV 23.4%, NPV 79.6%) and 5th minute (sensitivity 20.3%, specificity 87.4%, PPV 7.6%, NPV 95.6%), and admission to NICU (sensitivity 20.3%, specificity 87.5%, PPV 13.3%, NPV 92.1%). The AUC for FBS pH to predict neonatal acidaemia was 0.59 (95%CI 0.59-0.68, p = 0.3) with similar performance to predict Apgar scores<7 at 1st minute (AUC 0.55, 95%CI 0.51-0.59, p = 0.004), 5th minute (AUC 0.55, 95%CI 0.48-0.62, p = 0.13), and admission to NICU (AUC 0.58, 95%CI 0.52-0.64, p = 0.002). Forty-one neonates had acidaemia (2.8%, 41/1422) at birth. There was no significant correlation in pH values between the FBS and the umbilical cord blood in this subgroup adjusted for sampling time intervals (r = 0.03, p = 0.83). CONCLUSIONS As an adjunct tool to cardiotocography, FBS offered limited value to predict neonatal acidaemia, low Apgar Scores and admission to NICU.
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Tsikouras P, Koukouli Z, Niesigk B, Manav B, Farmakides G, Csorba R, Galazios G, Teichmann AT. Predictive value of fetal scalp pH and base excess for fetal acidosis and poor neonatal outcome. J Matern Fetal Neonatal Med 2017; 31:3166-3171. [DOI: 10.1080/14767058.2017.1365132] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Panagiotis Tsikouras
- Department of Obstetrics and Gynecology, Democritus University of Thrace, Greece
| | - Zacharoula Koukouli
- Department of Obstetrics and Gynecology, Democritus University of Thrace, Greece
| | - Barbara Niesigk
- Department of Obstetrics and Gynecology, Clinicum Aschaffenburg, Teaching Hospital of University of Würzburg, Germany
| | - Bachar Manav
- Department of Obstetrics and Gynecology, Democritus University of Thrace, Greece
| | - George Farmakides
- Department of Obstetrics and Gynecology, Democritus University of Thrace, Greece
| | - Roland Csorba
- Department of Obstetrics and Gynecology, Clinicum Aschaffenburg, Teaching Hospital of University of Würzburg, Germany
| | - Georgios Galazios
- Department of Obstetrics and Gynecology, Democritus University of Thrace, Greece
| | - Alexander Tobias Teichmann
- Department of Obstetrics and Gynecology, Clinicum Aschaffenburg, Teaching Hospital of University of Würzburg, Germany
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Tahir Mahmood U, O’Gorman C, Marchocki Z, O’Brien Y, Murphy DJ. Fetal scalp stimulation (FSS) versus fetal blood sampling (FBS) for women with abnormal fetal heart rate monitoring in labor: a prospective cohort study. J Matern Fetal Neonatal Med 2017; 31:1742-1747. [DOI: 10.1080/14767058.2017.1326900] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Uzma Tahir Mahmood
- Academic Department of Obstetrics and Gynaecology, Coombe Women & Infants University Hospital & Trinity College, University of Dublin, Dublin, Ireland
| | - Catherine O’Gorman
- Academic Department of Obstetrics and Gynaecology, Coombe Women & Infants University Hospital & Trinity College, University of Dublin, Dublin, Ireland
| | - Zibi Marchocki
- Academic Department of Obstetrics and Gynaecology, Coombe Women & Infants University Hospital & Trinity College, University of Dublin, Dublin, Ireland
| | - Yvonne O’Brien
- Academic Department of Obstetrics and Gynaecology, Coombe Women & Infants University Hospital & Trinity College, University of Dublin, Dublin, Ireland
| | - Deirdre J. Murphy
- Academic Department of Obstetrics and Gynaecology, Coombe Women & Infants University Hospital & Trinity College, University of Dublin, Dublin, Ireland
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12
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Holzmann M, Wretler S, Nordström L. Absence of accelerations during labor is of little value in interpreting fetal heart rate patterns. Acta Obstet Gynecol Scand 2016; 95:1097-103. [PMID: 27301645 DOI: 10.1111/aogs.12939] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Accepted: 06/13/2016] [Indexed: 11/30/2022]
Abstract
INTRODUCTION The aim of this study was to investigate the correlation between increasing time since fetal heart rate (FHR) accelerations, positive (no acceleration) stimulation tests and fetal acidemia. MATERIAL AND METHODS Observational study of FHR recordings from 1070 laboring women with indication for fetal scalp blood sampling (FBS). FHR traces were scrutinized regarding acceleration at FBS and duration since most recent acceleration. The appraiser was blinded to the FBS result. RESULTS At the first sampling, 8.8% of fetuses had lactate concentration >4.8 mmol/L. There were no differences between those with recent accelerations (≤60 min), and absent accelerations (>60 min or never) prior to FBS (8.3% vs. 8.9%, p = 0.71). Corresponding analyses for subgroups were: fetuses with isolated absence of accelerations, 3.7% vs. 1.5% (p = 0.41), fetuses without decelerations (i.e. reduced variability and/or tachycardia), 6.1% vs. 5.1% (p = 0.81) and fetuses with serious decelerations (i.e. late or complicated variable), 15.0% vs. 16.1% (p = 0.87). Among fetuses with serious decelerations, increasing duration from most recent acceleration had a weak but statistically significant correlation to increased lactate concentration (rs = 0.12, p = 0.03). The positive likelihood ratio for acidemia with no response at FBS was 1.15. CONCLUSION In a population with FBS performed upon indication, there was no correlation between duration since last FHR acceleration and increased lactate concentration. The majority of fetuses are not acidemic even when the FHR trace is pathological and stimulation tests are only helpful when accelerations are provoked.
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Affiliation(s)
- Malin Holzmann
- Department of Women's and Children's Health, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden.
| | - Stina Wretler
- Department of Women's and Children's Health, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden
| | - Lennart Nordström
- Department of Women's and Children's Health, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden
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Kuehnle E, Herms S, Kohls F, Kundu S, Hillemanns P, Staboulidou I. Correlation of fetal scalp blood sampling pH with neonatal outcome umbilical artery pH value. Arch Gynecol Obstet 2016; 294:763-70. [DOI: 10.1007/s00404-016-4053-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2015] [Accepted: 02/16/2016] [Indexed: 11/28/2022]
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Prior T, Kumar S. Expert review--identification of intra-partum fetal compromise. Eur J Obstet Gynecol Reprod Biol 2015; 190:1-6. [PMID: 25917435 DOI: 10.1016/j.ejogrb.2015.04.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2014] [Revised: 01/31/2015] [Accepted: 04/07/2015] [Indexed: 09/30/2022]
Abstract
Whilst most cases of cerebral palsy occur as a consequence of an ante-natal insult, a significant proportion, particularly in the term fetus, are attributable to intra-partum hypoxia. Intra-partum monitoring using continuous fetal heart rate assessment has led to an increased incidence of operative delivery without a concurrent reduction in the incidence of cerebral palsy. Despite this, birth asphyxia remains the strongest and most consistent risk factor for cerebral palsy in term infants. This review evaluates current intra-partum monitoring techniques as well as alternative approaches aimed at better identification of the fetus at risk of compromise in labour.
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Affiliation(s)
- Tomas Prior
- Centre for Fetal Care, Queen Charlotte's and Chelsea Hospital, Du Cane Road, London W12 0HS, UK; Institute for Reproductive and Developmental Biology, Imperial College London, London W12 0HS, UK
| | - Sailesh Kumar
- Centre for Fetal Care, Queen Charlotte's and Chelsea Hospital, Du Cane Road, London W12 0HS, UK; Institute for Reproductive and Developmental Biology, Imperial College London, London W12 0HS, UK; Mater Research Institute/University of Queensland, Aubigny Place, Raymond Terrace, South Brisbane, QLD 4101, Australia.
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Neonatal outcome and delivery mode in labors with repetitive fetal scalp blood sampling. Eur J Obstet Gynecol Reprod Biol 2015; 184:97-102. [DOI: 10.1016/j.ejogrb.2014.11.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2014] [Revised: 10/21/2014] [Accepted: 11/11/2014] [Indexed: 10/24/2022]
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Rhöse S, Heinis AM, Vandenbussche F, van Drongelen J, van Dillen J. Inter- and intra-observer agreement of non-reassuring cardiotocography analysis and subsequent clinical management. Acta Obstet Gynecol Scand 2014; 93:596-602. [DOI: 10.1111/aogs.12371] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2013] [Accepted: 02/27/2014] [Indexed: 01/16/2023]
Affiliation(s)
- Sarah Rhöse
- Department of Obstetrics and Gynecology; Radboud University Nijmegen Medical Center; Nijmegen the Netherlands
| | - Ayesha M.F. Heinis
- Department of Obstetrics and Gynecology; Radboud University Nijmegen Medical Center; Nijmegen the Netherlands
| | - Frank Vandenbussche
- Department of Obstetrics and Gynecology; Radboud University Nijmegen Medical Center; Nijmegen the Netherlands
| | - Joris van Drongelen
- Department of Obstetrics and Gynecology; Radboud University Nijmegen Medical Center; Nijmegen the Netherlands
| | - Jeroen van Dillen
- Department of Obstetrics and Gynecology; Radboud University Nijmegen Medical Center; Nijmegen the Netherlands
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van Laar JOEH, Warmerdam GJJ, Verdurmen KMJ, Vullings R, Peters CHL, Houterman S, Wijn PFF, Andriessen P, van Pul C, Guid Oei S. Fetal heart rate variability during pregnancy, obtained from non-invasive electrocardiogram recordings. Acta Obstet Gynecol Scand 2013; 93:93-101. [PMID: 24134552 DOI: 10.1111/aogs.12286] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2013] [Accepted: 10/12/2013] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Non-invasive spectral analysis of fetal heart rate variability is a promising new field of fetal monitoring. To validate this method properly, we studied the relationship between gestational age and the influence of fetal rest-activity state on spectral estimates of fetal heart rate variability. DESIGN Prospective longitudinal study. SETTING Tertiary care teaching hospital. POPULATION Forty healthy women with an uneventful singleton pregnancy. METHODS Non-invasive fetal electrocardiogram measurements via the maternal abdomen were performed at regular intervals between 14 and 40 weeks of gestation and processed to detect beat-to-beat fetal heart rate. Simultaneous ultrasound recordings were performed to assess fetal rest-activity state. MAIN OUTCOME MEASURES Absolute and normalized power of fetal heart rate variability in the low (0.04-0.15 Hz) and high (0.4-1.5 Hz) frequency band were obtained, using Fourier Transform. RESULTS 14% of all measurements and 3% of the total amount of abdominal data (330 segments) was usable for spectral analysis. During 21-30 weeks of gestation, a significant increase in absolute low and high frequency power was observed. During the active state near term, absolute and normalized low frequency power were significantly higher and normalized high frequency power was significantly lower compared with the quiet state. CONCLUSIONS The observed increase in absolute spectral estimates in preterm fetuses was probably due to increased sympathetic and parasympathetic modulation and might be a sign of autonomic development. Further improvements in signal processing are needed before this new method of fetal monitoring can be introduced in clinical practice.
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Affiliation(s)
- Judith O E H van Laar
- Department of Obstetrics and Gynecology, Máxima Medical Centre, Veldhoven, the Netherlands
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Do spectral bands of fetal heart rate variability associate with concomitant fetal scalp pH? Early Hum Dev 2013; 89:739-42. [PMID: 23809772 DOI: 10.1016/j.earlhumdev.2013.05.007] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2013] [Revised: 05/21/2013] [Accepted: 05/23/2013] [Indexed: 11/20/2022]
Abstract
BACKGROUND Objective information on specific fetal heart rate (FHR) parameters would be advantageous when assessing fetal responses to hypoxia. Small, visually undetectable changes in FHR variability can be quantified by power spectral analysis of FHR variability. AIMS To investigate the effect of intrapartum hypoxia and acidemia on spectral powers of FHR variability. STUDY DESIGN This is a retrospective observational clinical study with data from an EU multicenter project. SUBJECTS We had 462 fetuses with a normal pH-value (pH>7.20; controls) in fetal scalp blood sample (FBS) and 81 fetuses with a low scalp pH-value (≤ 7.20; low-FBS pH-fetuses). The low-FBS pH-fetuses were further divided into two subgroups according to the degree of acidemia: fetuses with FBS pH7.11-7.20 (n = 58) and fetuses with FBS pH ≤7.10 (n = 23). OUTCOME MEASURES Spectral powers of FHR variability in relation to the concomitant FBS pH-value. RESULTS Fetuses with FBS pH ≤7.20 had increased spectral powers of FHR variability compared with controls (2.49 AU vs. 2.23 AU; p = 0.038). However, the subgroup of most affected fetuses (those with FBS pH ≤7.10) had significantly lower FHR variability spectral powers when compared to fetuses with FBS pH7.11-7.20. CONCLUSIONS This study shows that spectral powers of FHR variability change as a fetus becomes hypoxic, and that spectral powers decrease with deepening fetal acidemia.
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O'Brien YM, Murphy DJ. The reliability of foetal blood sampling as a test of foetal acidosis in labour. Eur J Obstet Gynecol Reprod Biol 2012; 167:142-5. [PMID: 23270744 DOI: 10.1016/j.ejogrb.2012.11.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2012] [Revised: 11/09/2012] [Accepted: 11/28/2012] [Indexed: 12/17/2022]
Abstract
OBJECTIVES To establish whether foetal blood sampling for pH is a reliable test of foetal acidosis in labour by comparing paired foetal blood samples taken at a single procedure. STUDY DESIGN We conducted a prospective study assessing 293 consecutive attempts at foetal blood sampling in labour over a four month period from February to May 2012. A total of 100 paired samples were suitable for analysis. We compared the consistency of pH results of paired foetal blood samples, evaluated cases where inconsistent results would result in conflicting clinical decisions, and explored factors associated with discordant results. RESULTS There was a statistically significant difference between the mean pH of the two samples: 7.297 (SD 0.065) versus 7.315 (SD 0.059), p<0.0005. Of the 100 paired samples, 43 had a difference greater than the laboratory acceptable maximum analytical difference of 0.038. There was discordance between the samples in 16 cases with results crossing a decision threshold, and in 11 cases (69%) delivery was by emergency caesarean section. Inconsistent results were not associated with specific clinical factors and occurred more often with senior operators. CONCLUSION Foetal blood sampling is considered by many as the gold standard in assessing intrapartum foetal wellbeing. We have demonstrated inconsistency of paired foetal blood pH results which suggests that foetal blood sampling should not be considered infallible.
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Affiliation(s)
- Yvonne M O'Brien
- Academic Department of Obstetrics and Gynaecology, Coombe Women & Infants University Hospital & Trinity College, University of Dublin, Dublin 8, Ireland
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Authors’ Response. Eur J Obstet Gynecol Reprod Biol 2012. [DOI: 10.1016/j.ejogrb.2012.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Dudenhausen JW. The aim of FBS in labour is to detect hypoxia. Eur J Obstet Gynecol Reprod Biol 2011; 161:114; author reply 114-5. [PMID: 22000997 DOI: 10.1016/j.ejogrb.2011.09.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2011] [Accepted: 09/02/2011] [Indexed: 10/16/2022]
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Renevier B, Le Ray C, Cabrol D, Goffinet F. [Value of fetal scalp pH sampling early during the first stage of labour]. ACTA ACUST UNITED AC 2011; 40:535-40. [PMID: 21733639 DOI: 10.1016/j.jgyn.2011.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2010] [Revised: 04/22/2011] [Accepted: 05/27/2011] [Indexed: 11/17/2022]
Abstract
OBJECTIVE When fetal heart rate (FHR) abnormalities occur early during the first stage of labour, the risk of caesarean increases. In this study, we assessed the value of fetal scalp pH sampling on delivery mode, among women with FHR abnormalities before or at 5 cm cervical dilatation. METHODS It is a retrospective observational study setting in a tertiary maternity center. All women with a live singleton cephalic fetus at term, who had a fetal scalp pH sampling, between January and July 2009, were included. We compared vaginal delivery and neonatal morbidity rates according to cervical dilatation at the time of the first fetal scalp pH sampling (≤ 5 or >5 cm). Neonatal morbidity was defined by pH at birth less or equal to 7.10 and/or 5 minutes Apgar score less or equal to 7 and/or neonatal transfer. RESULTS During the study period, 108 women had at least one fetal scalp pH sampling, 8.5% of eligible women. Forty-six (42.6%) had a first pH at or before 5 cm cervical dilatation. The vaginal delivery rate was 62% and increased with increasing cervical dilatation at the time of the first fetal scalp pH (P<0.001). Among women who had fetal scalp pH early during the first stage of labour (≤ 5 cm), 50% delivered vaginally versus 71% when the fetal scalp pH was performed after 5 cm (P=0.026). The frequency of pH at birth less or equal to 7.10 was lower when the fetal scalp pH was performed before or at 5 cm (4.4% versus 16.9%, P=0.04). Neonatal morbidity rates were similar in both groups. CONCLUSION In this study, when FHR abnormalities occur early during the first stage of labour, use of fetal scalp pH sampling allows a vaginal delivery in half of cases without an increase in neonatal morbidity.
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Affiliation(s)
- B Renevier
- Assistance publique des hôpitaux de Paris, groupe hospitalier Cochin Broca-Hôtel-Dieu, maternité Port-Royal, université Paris Descartes, 123, boulevard de Port-Royal, 75014 Paris, France
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