Cesarean Delivery for Nonreassuring Fetal Heart Rate Tracing

Endocavity ultrasound and photoacoustic system for fetal and maternal imaging: design, implementation, and ex-vivo validation

Purpose: Transvaginal ultrasound (TVUS) is a widely used real-time and non-invasive imaging technique for fetal and maternal care. It can provide structural and functional measurements about the fetal brain, such as blood vessel diameter and blood flow. However, it lacks certain biochemical estimations, such as hemoglobin oxygen saturation ( SO 2 ), which limits its ability to indicate a fetus at risk of birth asphyxia. Photoacoustic (PA) imaging has been steadily growing in recognition as a complement to ultrasound (US). Studies have shown PA imaging is capable of providing such biochemical estimations as SO 2 at relatively high penetration depth (up to 30 mm). Approach: In this study, we have designed and developed a multi-modal (US, PA, and Doppler) endocavity imaging system (ECUSPA) around a commercialized TVUS probe (Philips ATL C9-5). Results: The integrated system was evaluated through a set of in-vitro, ex-vivo, and in-vivo studies. Imaging of excised sheep brain tissue demonstrated the system's utility and penetration depth in transfontanelle imaging conditions. The accuracy of using the spectroscopic PA imaging (sPA) method to estimate SO 2 was validated by comparing sPA oximetry results with the gold standard measurements indicated by a blood gas analyzer. The ability of US and Doppler to measure moving blood volume was evaluated in-vivo. Spectral unmixing capabilities were tested using fluorophores within sheep brains. Conclusion: The developed system is a high resolution (about 200    μ m at 30 mm depth), real-time (at 30 Hz), and quantitative ( SO 2 estimation error < 10 % ) imaging tool with a total diameter less than 30 mm, making it suitable for intrapartum applications such as fetal and maternal diagnostics.

Intrapartum Cesarean Delivery Due to Nonreassuring Fetal Heart Rate and the Risk of Pediatric Infectious Morbidity-related Hospitalizations of the Offspring

OBJECTIVES

One of the most common indications for intrapartum cesarean delivery (CD) is nonreassuring fetal heart rate (NRFHR) patterns. We aimed to study the long-term effect of CD due to NRFHR on the risk for subsequent childhood infectious morbidity-related hospitalizations of the offspring.

STUDY DESIGN

A population-based cohort study was performed, comparing total and different subtypes of infectious morbidity-related pediatric hospitalizations among offspring born by CD due to NRFHR versus labor dystocia (failure of labor to progress during the 1st or 2nd stage). The analysis included all singletons born between the years 1999-2014 at a single tertiary regional medical center. Infectious-related morbidities included hospitalizations involving a predefined set of International Classification of Diseases, 9th revision codes, as recorded in hospital computerized files. Infants with congenital malformations, multiple gestations, vaginal deliveries and vacuum failure were excluded from the analysis. Perinatal mortality cases were excluded from the long-term analysis. A Kaplan-Meier survival curve was used to compare the cumulative morbidity, and a Cox proportional hazards model was constructed to adjust for confounders.

RESULTS

The study population included 9956 newborns who met inclusion criteria; among them, 5810 (58%) were born by CD due to NRFHR, and 4146 (42%) were born via CD following labor dystocia with normal fetal heart rate (comparison group). Offspring born following NRFHR had higher rates of infectious morbidity-related hospitalizations (11.4% vs. 9.1%; odds ratio, 1.3; 95% confidence interval, 1.1-1.5; P < 0.01; Kaplan-Meier survival curve P < 0.01). The association remained significant and independent while adjusting for gestational age, maternal age and comorbidities, using a Cox proportional hazards model (adjusted hazard ratio, 1.3; 95% confidence interval, 1.2-1.4; P < 0.01).

CONCLUSIONS

In our population, CD due to NRFHR is a risk factor for pediatric infectious morbidity-related hospitalizations of the offspring.

Non-reassuring fetal heart rate patterns: Is it a risk factor for long- term pediatric cardiovascular diseases of the offspring?

OBJECTIVE

We aimed to study the long-term effect of non-reassuring fetal heart rate (NRFHR) patterns on the risk for subsequent pediatric cardiovascular morbidity of the offspring.

STUDY DESIGN

A population based cohort study, comparing total and different subtypes of cardiovascular morbidity related pediatric hospitalizations among offspring born by caesarean delivery (CD) due to NRFHR versus labor dystocia (failure of labor to progress during the 1st or 2nd stage). The analysis included all singletons born between the years 1999-2014 at a single tertiary regional medical center. Cardiovascular related morbidities included hospitalizations involving a pre-defined set of ICD-9 codes, as recorded in hospital computerized files. Infants with congenital malformations, multiple gestations, vaginal deliveries and vacuum failure were excluded from the analysis. Perinatal mortality cases were excluded from the long-term analysis. A Kaplan-Meier survival curve was used to compare the cumulative cardiovascular morbidity incidence, and a Cox proportional hazards model was used to adjust for confounders.

RESULTS

The study population included 9956 newborns who met inclusion criteria; among them, 5810 (58%) were born by CD due to NRFHR, and 4146 (42%) due to labor dystocia with normal FHR (comparison group). Rate of long- term cardiovascular related hospitalizations was comparable between both groups (0.8% vs. 0.7%, OR 0.9, 95% CI 0.6-1.4, p = 0.664; Kaplan-Meier survival curve p = 0.320(. Using a Cox proportional hazards model, controlling for gestational age, no association was found between NRFHR patterns and the risk for subsequent pediatric cardiovascular morbidity of the offspring (Adjusted HR = 0.8, 95% CI 0.5-1.3, p = 0.376).

CONCLUSION

In our population, NRFHR patterns do not affect the risk of long- term pediatric cardiovascular morbidity of the offspring.

Do Cesarean Delivery rates rise when the economy declines? A test of the economic stress hypothesis

A growing body of research supports the Barker hypothesis that adverse conditions around the time of birth have a negative effect on health. Nevertheless, the mechanisms linking early life conditions with health are still unclear. This paper investigates one of such potential mechanisms, specifically, ambient stress, by analyzing the effect of economic downturns as a stressor on the probability of Cesarean Delivery (CD). I focus particularly on male CD since the literature reports that male fetuses are more sensitive to stressors in utero than female fetuses. Using data from Lifelines, a large cohort study from the northern Netherlands, I show that the probability of CD for male babies increases when unemployment levels rise. This result suggests that maternal stress might be one of the mechanisms how early life economic conditions affect health.

Economic downturns and male cesarean deliveries: a time-series test of the economic stress hypothesis

Background

In light of the recent Great Recession, increasing attention has focused on the health consequences of economic downturns. The perinatal literature does not converge on whether ambient economic declines threaten the health of cohorts in gestation. We set out to test the economic stress hypothesis that the monthly count of cesarean deliveries (CD), which may gauge the level of fetal distress in a population, rises after the economy declines. We focus on male CD since the literature reports that male more than female fetuses appear sensitive to stressors in utero.

Methods

We tested our ecological hypothesis in California for 228 months from January 1989 to December 2007, the most recent data available to us at the time of our tests. We used as the independent variable the Bureau of Labor Statistics unadjusted total state employment series. Time-series methods controlled for patterns of male CD over time. We also adjusted for the monthly count of female CD, which controls for well-characterized factors (e.g., medical-legal environment, changing risk profile of births) that affect CD but are shared across infant sex.

Results

Findings support the economic stress hypothesis in that male CD increases above its expected value one month after employment declines (employment coefficient = -24.09, standard error = 11.88, p = .04). Additional exploratory analyses at the metropolitan level indicate that findings in Los Angeles and Orange Counties appear to drive the State-level relation.

Conclusions

Contracting economies may perturb the health of male more than female fetuses sufficiently enough to warrant more CD. Male relative to female CD may sensitively gauge the cohort health of gestations.

Clustering of maternal-fetal clinical conditions and outcomes and placental lesions

OBJECTIVE

To identify by an inductive statistical analysis mutually similar and clinically relevant clinicoplacental clusters.

STUDY DESIGN

Twenty-nine maternofetal and 49 placental variables have been retrospectively analyzed in a 3382 case clinicoplacental database using a hierarchical agglomerative Ward dendrogram and multidimensional scaling.

RESULTS

The exploratory cluster analysis identified 9 clinicoplacental (macerated stillbirth, fetal growth restriction, placenta creta, acute fetal distress, uterine hypoxia, severe ascending infection, placental abruption, and mixed etiology [2 clusters]), 5 purely placental (regressive placental changes, excessive extravillous trophoblasts, placental hydrops, fetal thrombotic vasculopathy, stem obliterative endarteritis), and 1 purely clinical (fetal congenital malformations) statistically significant clusters/subclusters. The clusters of such variables like clinical umbilical cord compromise, preuterine and postuterine hypoxia, gross umbilical cord or gross chorionic disk abnormalities did not reveal statistically significant stability.

CONCLUSION

Although clinical usefulness of several well-established placental lesions has been confirmed, claims about high predictability of others have not.

Refusal of emergency caesarean delivery in cases of non-reassuring fetal heart rate is an independent risk factor for perinatal mortality

OBJECTIVE

To assess pregnancy outcome in women who initially refused medically indicated caesarean delivery (CD) in cases of non-reassuring fetal heart rate (FHR) patterns.

STUDY DESIGN

A retrospective cohort study, comparing patients who refused and did not refuse caesarean delivery (CD) due to non-reassuring FHR tracings, was conducted. Deliveries occurred between the years 1988 and 2009 in a tertiary medical center. Multivariate analysis was performed to control for confounders.

RESULTS

Out of 10,944 women who were advised to undergo CD due to non-reassuring FHR patterns, 203 women initially refused CD. Women refusing medical intervention tended to be older (30.6 ± 6.9 vs. 28.29 ± 6.1, P<0.001) and of higher parity (46.8% vs. 19.9% had more than 5 deliveries; P<0.001) as compared to the comparison group. Refusal of CD was significantly associated with adverse perinatal outcome. Using a multiple logistic regression model controlling for confounders such as maternal age, refusal of treatment was found as an independent risk factor for perinatal mortality (adjusted OR=3.3, C.I. 95% 1.8-5.9, P<0.001). A non-significant trend towards higher rates of adverse perinatal outcome was found when refusal latency time was longer than 20 min (OR=2, 95% CI 0.36-11.95; P=0.29).

CONCLUSION

Refusal of CD in cases of non-reassuring FHR tracings is an independent risk factor for perinatal mortality.