1
|
Jia YJ, Ghi T, Pereira S, Gracia Perez-Bonfils A, Chandraharan E. Pathophysiological interpretation of fetal heart rate tracings in clinical practice. Am J Obstet Gynecol 2023; 228:622-644. [PMID: 37270259 DOI: 10.1016/j.ajog.2022.05.023] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Revised: 05/09/2022] [Accepted: 05/09/2022] [Indexed: 06/05/2023]
Abstract
The onset of regular, strong, and progressive uterine contractions may result in both mechanical (compression of the fetal head and/or umbilical cord) and hypoxic (repetitive and sustained compression of the umbilical cord or reduction in uteroplacental oxygenation) stresses to a human fetus. Most fetuses are able to mount effective compensatory responses to avoid hypoxic-ischemic encephalopathy and perinatal death secondary to the onset of anaerobic metabolism within the myocardium, culminating in myocardial lactic acidosis. In addition, the presence of fetal hemoglobin, which has a higher affinity for oxygen even at low partial pressures of oxygen than the adult hemoglobin, especially increased amounts of fetal hemoglobin (ie, 180-220 g/L in fetuses vs 110-140 g/L in adults), helps the fetus to withstand hypoxic stresses during labor. Different national and international guidelines are currently being used for intrapartum fetal heart rate interpretation. These traditional classification systems for fetal heart rate interpretation during labor are based on grouping certain features of fetal heart rate (ie, baseline fetal heart rate, baseline variability, accelerations, and decelerations) into different categories (eg, category I, II, and III tracings, "normal, suspicious, and pathologic" or "normal, intermediary, and abnormal"). These guidelines differ from each other because of the features included within different categories and because of their arbitrary time limits stipulated for each feature to warrant an obstetrical intervention. This approach fails to individualize care because the "ranges of normality" for stipulated parameters apply to the population of human fetuses and not to the individual fetus in question. Moreover, different fetuses have different reserves and compensatory responses and different intrauterine environments (presence of meconium staining of amniotic fluid, intrauterine inflammation, and the nature of uterine activity). Pathophysiological interpretation of fetal heart rate tracing is based on the application of the knowledge of fetal responses to intrapartum mechanical and/or hypoxic stress in clinical practice. Both experimental animal studies and observational human studies suggest that, just like adults undertaking a treadmill exercise, human fetuses show predictable compensatory responses to a progressively evolving intrapartum hypoxic stress. These responses include the onset of decelerations to reduce myocardial workload and preserve aerobic metabolism, loss of accelerations to abolish nonessential somatic body movements, and catecholamine-mediated increases in the baseline fetal heart rate and effective redistribution and centralization to protect the fetal central organs (ie, the heart, brain, and adrenal glands), which are essential for intrauterine survival. Moreover, it is essential to incorporate the clinical context (progress of labor, fetal size and reserves, presence of meconium staining of amniotic fluid and intrauterine inflammation, and fetal anemia) and understand the features suggestive of fetal compromise in nonhypoxic pathways (eg, chorioamnionitis and fetomaternal hemorrhage). It is important to appreciate that the timely recognition of the speed of onset of intrapartum hypoxia (ie, acute, subacute, and gradually evolving) and preexisting uteroplacental insufficiency (ie, chronic hypoxia) on fetal heart rate tracing is crucial to improve perinatal outcomes.
Collapse
Affiliation(s)
- Yan-Ju Jia
- Department of Obstetrics, Tianjin Key Laboratory of Human Development and Reproductive Regulation, Tianjin Central Hospital of Gynecology and Obstetrics, Nankai University Affiliated Hospital of Obstetrics and Gynecology, Tianjin, China
| | - Tullio Ghi
- Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Susana Pereira
- Kingston Hospital NHS Foundation Trust, Kingston upon Thames, England, United Kingdom
| | | | - Edwin Chandraharan
- Basildon University Hospital, Mid and South Essex NHS Foundation Trust, Basildon, United Kingdom.
| |
Collapse
|
2
|
Current Innovative Methods of Fetal pH Monitoring—A Brief Review. Diagnostics (Basel) 2022; 12:diagnostics12112675. [DOI: 10.3390/diagnostics12112675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 10/24/2022] [Accepted: 10/31/2022] [Indexed: 11/06/2022] Open
Abstract
In this study, we explore the “why?”, and “how?”, monitoring the pH of the fetal scalp is used, and show its limitations. In addition, we review the development of new devices based on the modern physics and nanomaterials serving this topic. Most of the works we found in our search have focused on improving the prognostic of fetal heart rate monitoring, because it is the “golden standard” in determining fetal distress. Although the best-known screening method, it can only provide limited information about the actual status of the fetus. The best predictive assessment, with the highest reproducibility, states that a normal fetal heart rate is indicative of a healthy baby. However, its excellent sensitivity is much reduced when identifying the actual “distress”. This is when second-line monitoring methods come into play to guide the diagnostics and direct the obstetrician towards an action plan. Although a historic method, fetal scalp pH sampling is still under review as to its efficiency and place in the current obstetrics. Continuous surveillance of the fetal parameters is important, especially for the fetuses undergoing intrauterine growth restricted (IUGR). Since fetal scalp blood sampling is still under research and is a randomized controlled trial, which compares the relevance of pH and lactates to the obstetrical situation, the maternal-fetal medicine could greatly benefit from the introduction of engineered nanomedicines to the field.
Collapse
|
3
|
West S, Ibiebele I, Nippita T. Intrapartum fetal blood sampling performed at early cervical dilatation and delivery outcomes. Aust N Z J Obstet Gynaecol 2020; 61:403-407. [PMID: 33382081 DOI: 10.1111/ajo.13294] [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: 04/08/2020] [Accepted: 11/24/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Intrapartum fetal blood sampling (FBS) is a fetal well-being diagnostic test for cardiotocogram abnormalities. AIM The aim of this study was to determine whether women who had their first FBS at <4 cm cervical dilation had an increased risk of operative delivery (caesarean section, instrumental delivery) compared to those women who had their first FBS ≥ 4 cm dilation. MATERIALS AND METHODS Retrospective cohort study involving labouring women who underwent FBS in a tertiary centre between 2015 and 2017. Women who had their first FBS at <4 cm dilation were compared to those who had their first FBS at ≥4 cm. The primary outcome was operative delivery (caesarean, instrumental delivery); secondary outcomes were neonatal complications. Univariate logistic regression was used to assess the association between degree of cervical dilation at first FBS and study outcomes. RESULTS Among 591 women, 39 (6.6%) had their first FBS at <4 cm cervical dilation. Women in the ≥4 cm group were less likely to have a total of ≥2 FBS (P = 0.003). There was no difference in the primary outcome between the two groups. Women who had the first FBS at <4 cm dilation were twice as likely to have a caesarean section delivery (odds ratio 2.06, 95% confidence interval 1.06-3.98), although 41% had a vaginal birth (instrumental and spontaneous). There were no differences in rates of resuscitation or admission to nursery between groups. CONCLUSION Women who had their first FBS < 4cm cervical dilation were twice as likely to have a caesarean section compared to women who had their first FBS ≥ 4 cm. However, 41% had a vaginal birth, and there were no differences in fetal outcomes.
Collapse
Affiliation(s)
- Simon West
- Department of Obstetrics and Gynaecology, Royal North Shore Hospital, St Leonards, New South Wales, Australia.,Sydney Medical School - Northern, The University of Sydney, Sydney, New South Wales, Australia.,Women and Babies Research, Kolling Institute, Northern Sydney Local Health District, St Leonards, New South Wales, Australia
| | - Ibinabo Ibiebele
- Sydney Medical School - Northern, The University of Sydney, Sydney, New South Wales, Australia.,Women and Babies Research, Kolling Institute, Northern Sydney Local Health District, St Leonards, New South Wales, Australia
| | - Tanya Nippita
- Department of Obstetrics and Gynaecology, Royal North Shore Hospital, St Leonards, New South Wales, Australia.,Sydney Medical School - Northern, The University of Sydney, Sydney, New South Wales, Australia.,Women and Babies Research, Kolling Institute, Northern Sydney Local Health District, St Leonards, New South Wales, Australia
| |
Collapse
|
4
|
Oikonomou M, Chandraharan E. Fetal heart rate monitoring in labor: from pattern recognition to fetal physiology. Minerva Obstet Gynecol 2020; 73:19-33. [PMID: 33238664 DOI: 10.23736/s2724-606x.20.04666-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The journey of human labor involves hypoxic and mechanical stresses as a result of progressively increasing frequency, duration and strength of uterine contractions and resultant compression of the umbilical cord. In addition, occlusion of the spiral arteries during myometrial contractions also leads to repetitive interruptions in the utero-placental circulation, predisposing a fetus to progressively worsening hypoxic stress as labor progresses. The vast majority of fetuses are equipped with compensatory mechanisms to withstand these hypoxic and mechanical stresses. They emerge unharmed at birth. However, some fetuses may sustain an antenatal injury or experience a chronic utero-placental insufficiency prior to the onset of labor. These may impair the fetus to compensate for the ongoing hypoxic stress secondary to ongoing uterine contractions. Non-hypoxic pathways of neurological damage such as chorioamnionitis, fetal anemia or an acute fetal hypovolemia may potentiate fetal neurological injury, especially in the presence of a super-imposed, additional hypoxic stress. The use of utero-tonic agents to induce or augment labor may increase the risk of hypoxic-ischemic injury. Clinicians need to move away from "pattern recognition" guidelines ("normal," "suspicious," "pathological"), and apply the knowledge of fetal physiology to differentiate fetal compensation from decompensation. Individualization of care is essential to optimize outcomes.
Collapse
Affiliation(s)
- Maria Oikonomou
- Department of Obstetrics and Gynecology, Watford General Hospital, Watford, UK -
| | - Edwin Chandraharan
- Department of Intrapartum Care Obstetrics and Gynecology, Basildon and Thurrock University Hospital, Basildon, UK
| |
Collapse
|
5
|
Shakouri F, Iorizzo L, Edwards HMK, Vinter CA, Kristensen K, Isberg PE, Wiberg N. Effectiveness of fetal scalp stimulation test in assessing fetal wellbeing during labor, a retrospective cohort study. BMC Pregnancy Childbirth 2020; 20:347. [PMID: 32503518 PMCID: PMC7275571 DOI: 10.1186/s12884-020-03030-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 05/22/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND It is discussed whether fetal scalp stimulation (FSS) test is a reliable complimentary tool to cardiotocography (CTG) to assess fetal wellbeing during labor. The test is based on the assumption that a well-oxygenated fetus, in contrast to the depressed fetus, will respond to a certain stimulus. The aim of this study was to investigate the effectiveness of the FSS-test. METHODS A retrospective observational study carried out Copenhagen University Hospital, Herlev, Denmark. Laboring women with singleton pregnancies in cephalic presentation after gestation week 33 and indication for fetal blood sampling (FBS) were eligible for inclusion. The FSS-test was classified as positive when an acceleration was absent at the time of FBS and negative when an acceleration was present. Lactate in scalp blood was measured by the point-of-care device LactatePro™ and pH in artery umbilical cord blood by the stationary blood gas analyzer ABL800. Lactate level < 4.2 mmol/L in scalp blood and arterial cord pH > 7.1 were cut-offs for normality. RESULTS Three hundred eighty-five women were included. The cohort was divided by the FBS-to-delivery time: Group 1 (n = 128) ≤ 20 min, Group 2 (n = 117) 21-59 min and Group 3 (n = 140) ≥ 60 min. The proportion of FSS-positive tests differed significantly between the groups (p < 0.000). In Group 1 the sensitivity, specificity and likelihoods for scalp lactate ≥4.2 mmol/L were 81.5 (95% CI 67-90.1), 13.3 18.5 (95% CI 5.9-24.6), LHR+ 0.94 (95% CI 0.8-1.1) and LHR - 1.4 (95% CI 0.6-3.2) and for umbilical artery pH ≤ 7.10 the values were 82.6% (95% CI 61.2-95.1), 16% (95% CI 9.4-24.7), 1.0 (95% CI 0.8-1.2) and 1.1 (95% CI 0.4-3) respectively. Regardless of the FBS-to-delivery time the LHR+ for lactate ≥4.2 mmol/L increased to 1.38 (95% CI 1.2-1.6). CONCLUSION The effectiveness of scalp stimulation test was poor for both ruling in and out fetal hypoxia during labor. Absence of a provoked acceleration seems to be a normal phenomenon in the second stage of labor.
Collapse
Affiliation(s)
- Farzaneh Shakouri
- Department of Gynecology and Obstetrics, Sjælland University Hospital, Roskilde, Denmark
| | - Linda Iorizzo
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden.
- Department of Gynecology and Obstetrics, Helsingborg Hospital, Helsingborg, Sweden.
| | - Hellen Mc Kinnon Edwards
- Department of Gynecology and Obstetrics, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Christina Anne Vinter
- Department of Gynecology and Obstetrics, Odense University Hospital, Odense, Denmark
- Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Karl Kristensen
- Department of Clinical Sciences Lund, Gynecology and Obstetrics, Lund University, Faculty of Medicine, Lund, Sweden
| | | | - Nana Wiberg
- Department of Clinical Sciences Lund, Gynecology and Obstetrics, Lund University, Faculty of Medicine, Lund, Sweden
- Department of Gynecology and Obstetrics, Skåne University Hospital, Ystad, Sweden
| |
Collapse
|
6
|
Amer-Wåhlin I, Ugwumadu A, Yli BM, Kwee A, Timonen S, Cole V, Ayres-de-Campos D, Roth GE, Schwarz C, Ramenghi LA, Todros T, Ehlinger V, Vayssiere C. Fetal electrocardiography ST-segment analysis for intrapartum monitoring: a critical appraisal of conflicting evidence and a way forward. Am J Obstet Gynecol 2019; 221:577-601.e11. [PMID: 30980794 DOI: 10.1016/j.ajog.2019.04.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Revised: 03/31/2019] [Accepted: 04/01/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND In the past century, some areas of obstetric including intrapartum care have been slow to benefit from the dramatic advances in technology and medical care. Although fetal heart rate monitoring (cardiotocography) became available a half century ago, its interpretation often differs between institutions and countries, its diagnostic accuracy needs improvement, and a technology to help reduce the unnecessary obstetric interventions that have accompanied the cardiotocography is urgently needed. STUDY DESIGN During the second half of the 20th century, key findings in animal experiments captured the close relationship between myocardial glycogenolysis, myocardial workload, and ST changes, thus demonstrating that ST waveform analysis of the fetal electrocardiogram can provide information on oxygenation of the fetal myocardium and establishing the physiological basis for the use of electrocardiogram in intrapartum fetal surveillance. RESULTS Six randomized controlled trials, 10 meta-analyses, and more than 20 observational studies have evaluated the technology developed based on this principle. Nonetheless, despite this intensive assessment, differences in study protocols, inclusion criteria, enrollment rates, clinical guidelines, use of fetal blood sampling, and definitions of key outcome parameters, as well as inconsistencies in randomized controlled trial data handling and statistical methodology, have made this voluminous evidence difficult to interpret. Enormous resources spent on randomized controlled trials have failed to guarantee the generalizability of their results to other settings or their ability to reflect everyday clinical practice. CONCLUSION The latest meta-analysis used revised data from primary randomized controlled trials and data from the largest randomized controlled trials from the United States to demonstrate a significant reduction of metabolic acidosis rates by 36% (odds ratio, 0.64; 95% confidence interval, 0.46-0.88) and operative vaginal delivery rates by 8% (relative risk, 0.92; 95% confidence interval, 0.86-0.99), compared with cardiotocography alone.
Collapse
|
7
|
Chandraharan E. Intrapartum care: An urgent need to question historical practices and ‘non-evidence’-based, illogical foetal monitoring guidelines to avoid patient harm. JOURNAL OF PATIENT SAFETY AND RISK MANAGEMENT 2019. [DOI: 10.1177/2516043519878583] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Edwin Chandraharan
- Children & Women's Directorate, St. George’s University Hospitals NHS Foundation Trust, London, UK
- Honorary Senior Lecturer, St. George’s University of London, London, UK
- Tianjin Central Hospital of Gynecology & Obstetrics, Tianjin, China
| |
Collapse
|
8
|
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.
Collapse
|
9
|
Kapaya H, Williams R, Elton G, Anumba D. Can Obstetric Risk Factors Predict Fetal Acidaemia at Birth? A Retrospective Case-Control Study. J Pregnancy 2018; 2018:2195965. [PMID: 30245882 PMCID: PMC6139200 DOI: 10.1155/2018/2195965] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 07/19/2018] [Accepted: 07/30/2018] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Despite major advances in perinatal medicine, intrapartum asphyxia remains a leading and potentially preventable cause of perinatal mortality and long-term morbidity. The umbilical cord pH is considered an essential criteria for the diagnosis of acute intrapartum hypoxic events. The purpose of this study was to evaluate whether obstetric risk factors are associated with fetal acidaemia at delivery. METHODOLOGY In a case-control study, 294 women with term singleton pregnancies complicated by an umbilical artery cord pH < 7.20 at birth were individually matched by controls with umbilical artery cord pH > 7.20. Groups were compared for differences in maternal, obstetric, and fetal characteristics using logistic regression models presented as odds ratio (OR) with 95% confidence intervals (CI). RESULTS The study showed pregestational diabetes (PGDM) [OR: 5.31, 95% CI: 1.15- 24.58, P = 0.018], urinary tract infection (UTI) [OR: 3.21, 95% CI: 1.61- 6.43, P < 0.001], and low Apgar scores to be significantly associated with acidaemia, whereas low maternal BMI [OR: 0.19, 95% CI: 0.04-0.87, P = 0.032], pyrexia in labour [OR 0.23; 95% CI 0.12-0.53; P < 0.001], electronic fetal monitoring (EFM) [OR 0.65; 95% CI 0.43-0.99; P = 0.042), and emergency caesarean section [OR 0.42; 95% CI 0.26-0.66; P < 0.001] were found to be protective of acidaemia. CONCLUSION Certain obstetric risk factors before and during labour can identify newborns at risk of developing acidaemia. Further research is needed to gain quantitative insight into the predictive capacity of these risks that can inform obstetric clinical management for improved outcomes.
Collapse
Affiliation(s)
- Habiba Kapaya
- Department of Oncology and Metabolism, Academic Unit of Reproductive & Developmental Medicine, 4th Floor Jessop Wing, Tree Root Walk, Sheffield S102SF, UK
| | - Roslyn Williams
- Department of Oncology and Metabolism, Academic Unit of Reproductive & Developmental Medicine, 4th Floor Jessop Wing, Tree Root Walk, Sheffield S102SF, UK
| | - Grace Elton
- Department of Oncology and Metabolism, Academic Unit of Reproductive & Developmental Medicine, 4th Floor Jessop Wing, Tree Root Walk, Sheffield S102SF, UK
| | - Dilly Anumba
- Department of Oncology and Metabolism, Academic Unit of Reproductive & Developmental Medicine, 4th Floor Jessop Wing, Tree Root Walk, Sheffield S102SF, UK
| |
Collapse
|
10
|
Lu K, Holzmann M, Abtahi F, Lindecrantz K, Lindqvist PG, Nordstrom L. Fetal heart rate short term variation during labor in relation to scalp blood lactate concentration. Acta Obstet Gynecol Scand 2018; 97:1274-1280. [PMID: 29799630 DOI: 10.1111/aogs.13390] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Accepted: 05/22/2018] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Fetal heart rate short term variation (STV) decreases with severe chronic hypoxia in the antenatal period. However, only limited research has been done on STV during labor. We have tested a novel algorithm for a valid baseline estimation and calculated STV. To explore the value of STV during labor, we compared STV with fetal scalp blood (FBS) lactate concentration, an early marker in the hypoxic process. MATERIAL AND METHODS Software was developed which estimates baseline frequency using a novel algorithm and thereby calculates STV according to Dawes and Redman in up to four 30-minute blocks prior to each FBS. Cardiotocography traces from 1070 women in labor who had had FBS performed on 2134 occasions were analyzed. RESULTS In acidemic cases (lactate >4.8 mmol/L; Lactate Pro™), median STV 30 minutes prior to FBS was 7.10 milliseconds compared with 6.09 milliseconds in the preacidemic (4.2-4.8 mmol/L) and 5.23 milliseconds in the normal (<4.2 mmol/L) groups (P < .05). There was a positive correlation between lactate and STV (rho = 0.16-0.24; P < .05). Median lactate concentration in cases with STV <3.0 milliseconds (n = 160) was 2.3 mmol/L. When 2 FBS were performed within 60 minutes the change rate of lactate correlated to STV (rho = 0.33; P < .001). Cases with increasing lactate concentration had a median STV of 5.29 milliseconds vs 4.41 milliseconds in those with decreasing lactate (P < .001). CONCLUSIONS In the early stages of intrapartum hypoxia, STV increases, contrary to findings regarding chronic hypoxia in the antenatal period. The increase in the adrenergic surge is a likely explanation.
Collapse
Affiliation(s)
- Ke Lu
- School of Technology and Health, Royal Institute of Technology, Stockholm, Sweden
| | - Malin Holzmann
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden.,Patient Area Pregnancy and Delivery Care, Karolinska University Hospital, Stockholm, Sweden
| | - Fahrad Abtahi
- Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden.,Department of Clinical Physiology, Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Kaj Lindecrantz
- School of Technology and Health, Royal Institute of Technology, Stockholm, Sweden.,Department of Clinical Science Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Pelle G Lindqvist
- Patient Area Pregnancy and Delivery Care, Karolinska University Hospital, Stockholm, Sweden.,Department of Clinical Science Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Lennart Nordstrom
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden.,Patient Area Pregnancy and Delivery Care, Karolinska University Hospital, Stockholm, Sweden
| |
Collapse
|
11
|
Vullings R, Verdurmen KMJ, Hulsenboom ADJ, Scheffer S, de Lau H, Kwee A, Wijn PFF, Amer-Wåhlin I, van Laar JOEH, Oei SG. The electrical heart axis and ST events in fetal monitoring: A post-hoc analysis following a multicentre randomised controlled trial. PLoS One 2017; 12:e0175823. [PMID: 28410419 PMCID: PMC5391944 DOI: 10.1371/journal.pone.0175823] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2016] [Accepted: 03/27/2017] [Indexed: 01/12/2023] Open
Abstract
OBJECTIVE Reducing perinatal morbidity and mortality is one of the major challenges in modern health care. Analysing the ST segment of the fetal electrocardiogram was thought to be the breakthrough in fetal monitoring during labour. However, its implementation in clinical practice yields many false alarms and ST monitoring is highly dependent on cardiotocogram assessment, limiting its value for the prediction of fetal distress during labour. This study aims to evaluate the relation between physiological variations in the orientation of the fetal electrical heart axis and the occurrence of ST events. METHODS A post-hoc analysis was performed following a multicentre randomised controlled trial, including 1097 patients from two participating centres. All women were monitored with ST analysis during labour. Cases of fetal metabolic acidosis, poor signal quality, missing blood gas analysis, and congenital heart disease were excluded. The orientation of the fetal electrical heart axis affects the height of the initial T/QRS baseline, and therefore the incidence of ST events. We grouped tracings with the same initial baseline T/QRS value. We depicted the number of ST events as a function of the initial baseline T/QRS value with a linear regression model. RESULTS A significant increment of ST events was observed with increasing height of the initial T/QRS baseline, irrespective of the fetal condition; correlation coefficient 0.63, p<0.001. The most frequent T/QRS baseline is 0.12. CONCLUSION The orientation of the fetal electrical heart axis and accordingly the height of the initial T/QRS baseline should be taken into account in fetal monitoring with ST analysis.
Collapse
Affiliation(s)
- Rik Vullings
- Department of Electrical Engineering, Eindhoven University of Technology, Eindhoven, the Netherlands
| | - Kim M. J. Verdurmen
- Department of Obstetrics and Gynaecology, Máxima Medical Centre, Veldhoven, the Netherlands
| | | | - Stephanie Scheffer
- Department of Obstetrics and Gynaecology, Máxima Medical Centre, Veldhoven, the Netherlands
| | - Hinke de Lau
- Department of Obstetrics and Gynaecology, Máxima Medical Centre, Veldhoven, the Netherlands
| | - Anneke Kwee
- Department of Obstetrics and Gynaecology, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Pieter F. F. Wijn
- Department of Clinical Physics, Máxima Medical Centre, Veldhoven, the Netherlands
| | - Isis Amer-Wåhlin
- Department of Women and Child Health, Karolinska Institute, Stockholm, Sweden
| | | | - S. Guid Oei
- Department of Electrical Engineering, Eindhoven University of Technology, Eindhoven, the Netherlands
- Department of Obstetrics and Gynaecology, Máxima Medical Centre, Veldhoven, the Netherlands
| |
Collapse
|
12
|
Barrois M, Chartier M, Lecarpentier E, Goffinet F, Tsatsaris V. [Per partum acidosis: Interest and feasibility of cerebral Doppler during labor]. GYNECOLOGIE, OBSTETRIQUE & FERTILITE 2016; 44:475-479. [PMID: 27568410 DOI: 10.1016/j.gyobfe.2016.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Accepted: 07/04/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVES To evaluate feasibility and interest of fetal cerebral Doppler during labor and the link with fetal pH to predict perinatal fetal asphyxia. METHODS Our prospective study in a university perinatal center, included patients during labor. There were no risk factors during pregnancy and patients were included after 37 weeks of pregnancy. For each patient an ultrasound with cerebral Doppler was done concomitant to a fetal scalp blood sample. We collected maternal and fetal characteristics as well as cervix dilatation, fetal heart rate analysis and fetal presentation. RESULTS Among 49 patients included over a period of 4 months, cerebral Doppler failed in 7 cases (11%). Majority of failure occurred at 10cm of dilatation (P=0.007, OR=14.1 [1.483; 709.1275]). Others factors like: maternal age, body mass index, parity, history of C-Section were not associated with higher rate of failure. We did not found either significant correlation between cerebral fetal Doppler and pH on fetal scalp blood sample (r=0.15) nor pH at cord blood sample (r=0.13). No threshold of cerebral Doppler is significant for fetal asphyxia prediction. CONCLUSION Fetal cerebral Doppler is feasible during labor with a low rate of failure but not a good exam to predict fetal acidosis and asphyxia.
Collapse
Affiliation(s)
- M Barrois
- Maternité Port-Royal, groupe hospitalier Broca-Cochin-Hôtel Dieu, 53, avenue de l'Observatoire, 75014 Paris, France.
| | - M Chartier
- Maternité Port-Royal, groupe hospitalier Broca-Cochin-Hôtel Dieu, 53, avenue de l'Observatoire, 75014 Paris, France
| | - E Lecarpentier
- Maternité Port-Royal, groupe hospitalier Broca-Cochin-Hôtel Dieu, 53, avenue de l'Observatoire, 75014 Paris, France; PRES Sorbonne Paris Cité, Université Paris Descartes, 75013 Paris, France; DHU risques et grossesse, 75014 Paris, France; PremUP foundation, 75014 Paris, France; Inserm, UMR-S 1139, physiopathologie et pharmacotoxicologie placentaire humaine, 75006 Paris, France
| | - F Goffinet
- Maternité Port-Royal, groupe hospitalier Broca-Cochin-Hôtel Dieu, 53, avenue de l'Observatoire, 75014 Paris, France; DHU risques et grossesse, 75014 Paris, France; Inserm, U-1153, 75004 Paris, France
| | - V Tsatsaris
- Maternité Port-Royal, groupe hospitalier Broca-Cochin-Hôtel Dieu, 53, avenue de l'Observatoire, 75014 Paris, France; PRES Sorbonne Paris Cité, Université Paris Descartes, 75013 Paris, France; DHU risques et grossesse, 75014 Paris, France; PremUP foundation, 75014 Paris, France; Inserm, UMR-S 1139, physiopathologie et pharmacotoxicologie placentaire humaine, 75006 Paris, France
| |
Collapse
|
13
|
Visser GH, Ayres-de-Campos D. FIGO consensus guidelines on intrapartum fetal monitoring: Adjunctive technologies. Int J Gynaecol Obstet 2016; 131:25-9. [PMID: 26433402 DOI: 10.1016/j.ijgo.2015.06.021] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Gerard H Visser
- Department of Obstetrics, University Medical Center, Utrecht, The Netherlands
| | - Diogo Ayres-de-Campos
- Medical School, Institute of Biomedical Engineering, S. Joao Hospital, University of Porto, Portugal
| | | |
Collapse
|