Assessment of the Fetus: Intermittent Auscultation, Electronic Fetal Heart Rate Tracing, and Fetal Pulse Oximetry

Uterine torsion as an elusive obstetrical emergency in pregnancy: is there an association between gravid uterus torsion and Ehlers-Danlos syndrome?: a case report

BACKGROUND

Timely diagnosis of uterine torsion can lead to acceptable maternal and fetal outcomes. This article presents the case of a 42-year-old pregnant woman, diagnosed with a rare 270° uterine torsion, in whom proper management led to good maternal outcomes but, unfortunately, severe prematurity and metabolic acidosis led to neonatal death. Moreover, the mother was clinically suspected for Ehlers-Danlos syndrome.

CASE PRESENTATION

In December 2020, a 42-year-old pregnant Iranian woman, Gravid 3 para2 live2, at 30 weeks of gestation presented to the obstetric emergency department of Vali-Asr Hospital (Birjand, Iran) suffering from acute severe generalized abdominal pain, nausea, vomiting, and dizziness while she was hemodynamically unstable. After resuscitation, owing to persistent fetal bradycardia on fetal heart rate monitoring, she underwent an emergency cesarean section. Infra-umbilical midline skin incision was made, and when the abdominal cavity was opened, owing to abnormal appearance of the uterus, we further investigated the abdominopelvic cavity. Surprisingly, the uterus was dextrorotated by 270°. After uterine detorsion through a Kerr incision, a nonvigorous male baby was born with severe metabolic acidosis that led to his death soon after birth. Interestingly, we could find no predisposing factors such as pelvic abnormalities during surgery. Nevertheless, as her postoperative detailed physical examination revealed skin hyperextensibility, joint laxity, pelvic organ prolapse, and trivial exophthalmos, connective tissue disorders, mainly Ehlers-Danlos syndrome, were suspected. Unfortunately, for significant financial, cultural, and religious reasons, the patient refused to undergo further investigations. Additionally, despite severe congested uterus and subsequent uterine atony, timely diagnosis and anatomical correction of the gravid uterus before uterine incision prevented iatrogenic complications. The mother was discharged 2 days later without any postpartum complications.

CONCLUSION

Although uterine torsion is an extremely rare condition during pregnancy, based on severe associated maternal and perinatal complications, it is important to take this diagnosis into consideration as an differential diagnosis. Moreover, connective tissue disorders seem to be a potential risk factor for uterine torsion, although further studies on this subject are required.

A Case of Abruptio Placentae due to the Torsion of Gravid Uterus

Torsion of a gravid uterus is a rare obstetric emergency potentially lethal for the fetus and the mother. Some of the cases described in literature are associated with preexisting gynecologic conditions related to pelvic and uterine anatomy, even if most of cases remain unexplained. We report a case of acute 180-degree torsion of uterus at 33 weeks of gestation associated with abruptio placentae in a young Asian woman without apparent risk factors.

The influence of maternal epidural analgesia upon intrapartum fetal oxygenation

OBJECTIVE

The use of maternal epidural analgesia in labor may be associated with non-reassuring fetal heart rate (FHR) patterns. We aimed to assess changes in fetal oxygen saturation (FSpO(2)) during epidural analgesia in labor.

METHODS

This was a prospective observational study. Twenty healthy parturients were enrolled following the inclusion criteria. Informed consent was obtained. Mode of delivery, use of oxytocin, maternal blood pressure, umbilical cord blood analysis, Apgar score, and neonatal outcomes were evaluated. Ropivacaine at a low concentration of 0.1% (1 mg/mL) co-administered with an opioid (fentanyl 2.5 microg/mL) was used. The values of fetal oxygen saturation were registered continuously 10 minutes before the administration of the analgesic drug and during the following 30 minutes after administration. Pulse oximetry was used simultaneously with cardiotocography (CTG).

RESULTS

The average value for fetal oxygen saturation before the analgesic drug administration was 44.3 +/- 8.8%; during the first 10 minutes following administration it was 41.3 +/- 7.2% (p = 0.25) and during the following 20 minutes it was 43.05% +/- 6.9% (p = 0.63). There was no direct relationship between non-reassuring CTG pattern appearance and FSpO(2) <30% (RR = 1.11, 95% CI 0.76-1.64). No significant correlation was found between FSpO(2) values within the first 30 minutes of epidural analgesia and neonatal acidotic status (pH <or=7.00; RR = 0.33, 95% CI 0.04-3.09, and base excess <or=-12 mmol/L; RR = 1, 95% CI 0.21-4.71).

CONCLUSIONS

There were no differences in FSpO(2) values in the first 30 minutes following administration of analgesic drugs and most of the cases with non-reassuring CTG patterns had values of FSpO(2) constantly >or=30%.

Real-time fetal heart monitoring in biomagnetic measurements using adaptive real-time ICA

Electrophysiological signals of the developing fetal brain and heart can be investigated by fetal magnetoencephalography (fMEG). During such investigations, the fetal heart activity and that of the mother should be monitored continuously to provide an important indication of current well-being. Due to physical constraints of an fMEG system, it is not possible to use clinically established heart monitors for this purpose. Considering this constraint, we developed a real-time heart monitoring system for biomagnetic measurements and showed its reliability and applicability in research and for clinical examinations. The developed system consists of real-time access to fMEG data, an algorithm based on Independent Component Analysis (ICA), and a graphical user interface (GUI). The algorithm extracts the current fetal and maternal heart signal from a noisy and artifact-contaminated data stream in real-time and is able to adapt automatically to continuously varying environmental parameters. This algorithm has been named Adaptive Real-time ICA (ARICA) and is applicable to real-time artifact removal as well as to related blind signal separation problems.

Fetal auditory responses to external sounds and mother's heart beat: detection improved by Independent Component Analysis

In this paper, we present a magnetoencephalographic study of the fetal auditory response to external stimuli and to the sound of the mother's heartbeat. We describe how an ad hoc functional selection procedure allowed us to isolate the sources in the fetal brain responding to sounds only, after the application to the recorded data of a standard Independent Component Analysis algorithm. In our experiment, acoustic stimuli were delivered to twelve healthy women with uncomplicated pregnancies at a time between 36 and 40 weeks gestational age, with their fetuses in breech presentation. Ultrasound images allowed determination of the region over the women's abdomen nearest to the fetal head, over which both the acoustic stimulator and the MEG sensors were subsequently placed. In 8 out of the 12 cases, our analysis provided consistent evidence of a fetal response both to the mother's heartbeat and to the external auditory stimulation; both were characterized by a clear prominent component at around 200 ms latency, which is widely accepted as the marker of the fetal response to auditory stimuli.